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Formulaire 6069 Instructions

Instructions pour le formulaire 6069, Déclaration de certaines taxes d'accise sur les exploitants miniers, les fiducies pulmonaires noires et les autres personnes en vertu des articles 4951, 4952 et 4953

Rev. Décembre 2021

Formulaires associés

  • Formulaire 6069 - Retour de certaines taxes d'accise sur les exploitants de mines, Fiducies pulmonaires noires et autres personnes en vertu des articles 4951, 4952 et 4953
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Department of the Treasury  
Internal Revenue Service  
Instructions for Form 6069  
(Rev. December 2021)  
Return of Certain Excise Taxes on Mine Operators, Black Lung Trusts, and Other  
Persons Under Sections 4951, 4952, and 4953  
Section references are to the Internal Revenue  
Code unless otherwise noted.  
for contributions made to black lung  
benefit trusts. Part IV of the form is also  
used to determine the amount of excise  
tax imposed under section 4953 for  
contributions that are more than the  
maximum allowable deduction.  
When filer is a coal mine operator. A  
coal mine operator completes Part III to  
figure the amount of its allowable  
Future Developments  
contributions for the tax year. The coal  
mine operator completes Part I and files  
Form 6069 only if contributions exceed the  
allowed contribution amount.  
For the latest information about  
developments related to Form 6069 and  
its instructions, such as legislation  
enacted after they were published, go to  
Who Must File  
Any person who is a disqualified person  
When and Where To File  
with respect to a black lung benefit trust  
and has incurred liability for the excise tax  
on self-dealing transactions under section  
4951.  
File Form 6069 by the 15th day of the 5th  
month after the end of your tax year. If the  
regular due date falls on a Saturday,  
Sunday, or legal holiday, file on the next  
business day. File it with the:  
What’s New  
Revised form. Form 6069 has been  
substantially reformatted to expand its  
use. Previously, Form 6069 was used  
exclusively by coal mine operators to  
compute their maximum allowable income  
tax deduction under section 192 and to  
determine the amount of any excise tax  
imposed under section 4953 for  
Any trustee of a black lung benefit trust  
that has incurred liability for the excise tax  
on the trustee in connection with any  
self-dealing transaction (section 4951) or  
taxable expenditure (section 4952).  
Internal Revenue Service Center  
333 W. Pershing Road  
Kansas City, MO 64108  
Any black lung benefit trust that has  
incurred liability for the excise tax on  
taxable expenditures (under section  
4952).  
To request an extension of time to file  
Form 6069, file Form 8868, Application for  
Automatic Extension of Time To File an  
Exempt Organization Return.  
contributions that exceed the allowable  
deduction. For tax years beginning on or  
after January 1, 2021, Form 6069 will also  
be used by section 501(c)(21) black lung  
benefit trusts to report and pay excise  
taxes imposed under section 4951  
(self-dealing) and 4952 (taxable  
Any coal mine operator that made  
excess contributions (under section 4953)  
must file Form 6069. A coal mine operator  
can complete Part IV, lines 1 through 7, to  
figure the maximum allowable deduction  
under section 192. Form 6069 must be  
filed only if the amount shown on Part IV,  
line 7, is greater than zero.  
Accounting Methods  
Use the accounting method regularly used  
in keeping your books and records.  
expenditures).  
Accounting Periods  
General Instructions  
Purpose of Form  
Black lung benefit trusts and certain  
other persons. The Black Lung Benefits  
Revenue Act of 1977 (the Act) amended  
the Code to impose an excise tax on the  
sale of coal and established a trust fund  
under section 501(c)(21) (funded by the  
coal tax and certain other revenues) to be  
available for expenses of providing  
Complete the return on the basis of your  
established accounting period. If you do  
not have an established accounting  
period, use the calendar year.  
A coal mine operator should not  
file Form 6069 if the information  
!
CAUTION  
entered in Part IV indicates that no  
excess contributions were made.  
Penalties and Interest  
Which Parts To Complete  
There are penalties for late filing, willful  
failure to file, and for filing fraudulent  
returns and statements. See sections  
6651, 7203, 7206, and 7207. Also see  
section 6684 for penalties that relate to  
excise tax liability under chapter 42.  
Interest charges for any unpaid tax are  
charged at the underpayment rate  
established under section 6621. The  
interest on underpayments is in addition to  
any penalties.  
When filer is a black lung benefit trust.  
A trust filing this form for a year in which  
there are initial taxes due under section  
4951 or 4952 completes Form 6069 as  
follows.  
medical benefits when not paid by the  
appropriate mine operator. The Act also  
added sections 4951 (self-dealing), 4952  
(taxable expenditures), and 4953 (excess  
contributions by mine operators) to  
Complete Parts II and III first, providing  
complete information about the  
self-dealing and taxable expenditure  
transactions and showing tax  
computations.  
impose excise taxes on certain acts. For  
tax years beginning on or after January 1,  
2021, black lung benefit trusts will use  
Form 990 to meet reporting requirements  
under section 6033. If initial taxes are  
imposed on the trust or certain related  
parties under section 4951 or 4952, the  
trust or related party will report the initial  
excise tax using Part II or Part III,  
Complete Part I, line 1, only. Do not  
Definitions  
include taxes that must be paid by the  
trustee or a self-dealer on any other line in  
Part I.  
The term “Black Lung Acts” refers to Part  
C of Title IV of the Federal Mine Safety  
and Health Act of 1977, and any state law  
that provides compensation for disability  
or death due to pneumoconiosis (black  
lung disease). A black lung benefit claim is  
a claim for compensation for disability or  
death due to pneumoconiosis under the  
Black Lung Acts. Unless otherwise  
When filer is a self-dealer. A self-dealer  
liable for initial taxes under section 4951  
completes Part II, then Part I.  
respectively, of Form 6069.  
When filer is a trustee. A trustee liable  
for initial excise taxes (sections 4951 and  
4952) completes Parts II and III (as  
applicable), and then Part I.  
Coal mine operators. A coal mine  
operator will now use Part IV of Form 6069  
to determine the maximum allowable  
income tax deduction (under section 192)  
indicated, the term “trust” as used in these  
Dec 15, 2021  
Cat. No. 749870  
instructions means the tax-exempt section  
501(c)(21) trust or trusts to which the coal  
mine operator made contributions for  
which it claimed a deduction under section  
192.  
2. The date on which the tax imposed  
by section 4951(a)(1) is assessed; or  
account under section 267(c), except that,  
for purposes of this paragraph, section  
267(c)(4) is treated as providing that the  
members of the family of an individual are  
only those individuals described in item 5.  
For purposes of items 3b and c, 7, and 8,  
the ownership of profits or beneficial  
interests is determined by the rules for  
constructive ownership of stock provided  
in section 267(c) (other than paragraph  
(3)), except that section 267(c)(4) is  
treated as providing that the members of  
the family of an individual are only those  
individuals described in item 5.  
3. The date on which correction of the  
act of self-dealing is completed.  
Amount involved. The term “amount  
involved” means, for any act of  
Self-Dealing (Section 4951)  
Self-dealing. For purposes of section  
4951, the term “self-dealing” means any  
direct or indirect:  
self-dealing, the greater of the amount of  
money and the fair market value (FMV) of  
the other property given or the amount of  
money and the FMV of the other property  
received. However, in the case of services  
described in section 4951(d)(2)(C), the  
amount involved is only the excess  
compensation. For purposes of the  
preceding sentence, the FMV:  
Sale, exchange, or leasing of real or  
personal property between a trust  
described in section 501(c)(21) and a  
disqualified person;  
Lending of money or other extension of  
Payment of benefits. For purposes of  
section 4951, a payment out of assets or  
income of a trust described in section  
501(c)(21) for the purposes described in  
sections 501(c)(21)(A)(i)(I) and 501(c)(21)  
(A)(i)(IV) is not considered an act of  
self-dealing.  
credit between such a trust and a  
disqualified person;  
1. For the initial taxes imposed by  
section 4951(a), is determined as of the  
date on which the act of self-dealing  
occurs; and  
2. For additional taxes imposed by  
section 4951(b), is the highest FMV during  
the taxable period.  
Furnishing of goods, services, or  
facilities between such a trust and a  
disqualified person;  
Payment of compensation (or payment  
or reimbursement of expenses) by such a  
trust to a disqualified person; and  
Taxable Expenditures (Section  
4952)  
Transfers to, or use by or for the benefit  
of, a disqualified person of the income or  
assets of such a trust.  
Correction. The terms “correction” and  
“correct” mean, for any act of self-dealing,  
undoing the transaction to the extent  
possible, but in any case, placing the trust  
in a financial position not worse than that  
in which it would be if the disqualified  
person were dealing under the highest  
fiduciary standards.  
Taxable expenditure. For purposes of  
section 4952, the term “taxable  
Special rules. For purposes of section  
expenditure” means any amount paid or  
incurred by a trust described in section  
501(c)(21) other than for a purpose  
specified in that section.  
4951:  
The transfer of personal property by a  
disqualified person to such a trust is  
treated as a sale or exchange if the  
property is subject to a mortgage or similar  
lien;  
Correction. The terms “correction” and  
“correct” mean, with respect to any  
taxable expenditure, placing the trust in a  
financial position not worse than that in  
which it would have been if the taxable  
expenditure had not been made:  
1. By recovering all or part of the  
expenditure to the extent recovery is  
possible; and  
2. When full recovery is not possible,  
by contributions by the person or persons  
whose liabilities for black lung benefit  
claims (as defined in section 192(e)) are to  
be paid out of the trust.  
Disqualified person. The term  
“disqualified person” means, for a trust  
described in section 501(c)(21), a person  
who is:  
If a bank or an insured credit union is a  
trustee of the trust or otherwise is a  
“disqualified person” with respect to the  
trust, any amount invested in checking  
accounts, savings accounts, certificates of  
deposit, or other time or demand deposits  
in that bank or credit union constitutes a  
lending of money;  
1. A contributor to the trust;  
2. A trustee of the trust;  
3. An owner of more than 10% of:  
a. The total combined voting power of  
The furnishing of goods, services, or  
a corporation,  
facilities by a disqualified person to such a  
trust is not an act of self-dealing if the  
furnishing is without charge and if the  
goods, services, or facilities so furnished  
are used exclusively for the purposes  
specified in section 501(c)(21)(A); and  
b. The profits interest of a partnership,  
or  
c. The beneficial interest of a trust or  
unincorporated enterprise that is a  
contributor to the trust;  
Taxable period. The term “taxable  
period” means, with respect to any taxable  
expenditure, the period beginning with the  
date on which the taxable expenditure  
occurs and ending on the earlier of:  
1. The date of mailing a notice of  
deficiency under section 6212, with  
respect to the tax imposed by section  
4952(a)(1); or  
The payment of compensation (and the  
4. An officer, director, or employee of  
payment or reimbursement of expenses)  
by such a trust to a disqualified person for  
personal services that are reasonable and  
necessary to carry out the exempt  
purpose of the trust is not an act of  
self-dealing if the compensation (or  
payment or reimbursement) is not  
excessive. See Regulations section  
53.4951-1 for additional information.  
a person who is a contributor to the trust;  
5. The spouse, ancestor, lineal  
descendant, or spouse of a lineal  
descendant of an individual described in  
(1), (2), (3), or (4);  
6. A corporation of which persons  
described in (1), (2), (3), (4), or (5) own  
more than 35% of the total combined  
voting power;  
7. A partnership in which persons  
described in (1), (2), (3), (4), or (5) own  
more than 35% of the profits interest; or  
8. A trust or estate in which persons  
described in (1), (2), (3), (4), or (5) hold  
more than 35% of the beneficial interest.  
2. The date on which the tax imposed  
by section 4952(a)(1) is assessed.  
Taxable period. The term “taxable  
period” means, with respect to any act of  
self-dealing, the period beginning with the  
date on which the act of self-dealing  
occurs and ending on the earliest of:  
1. The date of mailing of a notice of  
deficiency under section 6212, with  
respect to the tax imposed by section  
4951(a)(1);  
Specific Instructions  
Items A Through I  
Item A. Fill in the spaces to show the  
calendar year or fiscal year of the  
accounting period you are reporting.  
For purposes of items 3a and 6 above,  
indirect stockholdings are taken into  
account if they would be taken into  
A black lung benefit trust filing to report  
taxable expenditures (section 4952)  
-2-  
should enter the calendar or fiscal year of  
the trust.  
the next dollar. For example, $1.39  
becomes $1 and $2.50 becomes $3.  
person (other than a trustee acting only as  
such) who participated in the act of  
self-dealing.  
Disqualified persons and trustees who  
participate in acts of self-dealing with a  
black lung benefit trust and who have tax  
years different from the trust should use  
their own tax years to figure the initial tax  
and file the return.  
A coal mine operator filing Form 6069  
to report the excise tax on excess  
contributions (section 4953) should enter  
the calendar or fiscal year of the coal mine  
operator.  
If you have to add two or more amounts  
to figure the amount to enter on a line,  
include cents when adding the amounts  
and round off only the total.  
Initial section 4951 taxes on trustee.  
When a tax is imposed on an act of  
self-dealing, any trustee who knowingly  
participated in such an act must pay a tax  
of 2.5% of the amount involved in the act  
of self-dealing for each year (or part of a  
year) in the taxable period unless  
Part I. Tax and Payment  
Lines 1 through 5. See the specific line  
instructions for Parts II through IV for  
instructions applicable to each type of filer  
regarding amounts to be entered in Part I,  
lines 1 through 5.  
participation in the act was not willful and  
was due to reasonable cause.  
Line 1. List each act of self-dealing on  
line 1, providing the date and a brief  
description of each act in columns (b) and  
(c).  
Item B. Check box (1) if you are a black  
lung benefit trust liable for the section  
4952 tax on taxable expenditures.  
A coal mine operator should complete  
Part I and file Form 6069 only if the  
amount carried to Part I, line 2, from Part  
IV, line 8, is greater than zero.  
Check the appropriate box(es) on line  
Line 2. For each act of self-dealing listed  
on line 1, provide the following  
information.  
(2) if you are one or more of the following.  
Liability for tax. A person's liability for  
tax as a self-dealer or trustee under  
sections 4951 and 4952 is joint and  
several. Therefore, if more than one  
person is liable for tax on an act of  
self-dealing as a self-dealer or trustee,  
they may prorate the tax among  
A disqualified person liable for the  
section 4951 excise tax on self-dealing.  
In column (b), enter the names of all  
A trustee of a black lung benefit trust  
disqualified persons who took part in the  
acts of self-dealing listed on line 1.  
and are liable for the excise tax arising  
from your role in connection with a  
self-dealing transaction (section 4951) or  
taxable expenditure (section 4952).  
In column (c), enter the amount  
involved in each act of self-dealing.  
For each act of self-dealing, multiply  
the amount in column (c) by 0.10 and  
enter the amount in column (d). If more  
than one disqualified person took part in  
an act of self-dealing, each disqualified  
person is individually liable for the entire  
amount of the tax. Nonetheless, the  
disqualified persons who are liable for the  
tax may prorate the payment among  
themselves. If self-dealers prorate the  
excise tax, attach a statement showing the  
intended allocation of liability among the  
self-dealers.  
For each act of self-dealing, multiply  
the amount in column (c) by 0.025 and  
enter the amount in column (e). A trustee  
who took part in the act of self-dealing and  
who knew that the act was self-dealing  
(except for trustees whose participation  
was not willful and was due to reasonable  
cause) is liable for the tax in column (e).  
If more than one trustee took part in the  
act of self-dealing, knowing that it was  
such an act, and participation was willful  
and not due to reasonable cause, each is  
individually liable for the entire tax in  
connection with the act. Nonetheless, the  
trustees liable for the excise tax may  
prorate the payment among themselves.  
Attach a statement showing the name of  
each trustee liable for the tax in column (e)  
for each act of self-dealing.  
themselves. The IRS may assess a  
deficiency against one or more  
A coal mine operator liable for the  
section 4953 excise tax on excess  
self-dealers or trustees liable for the tax  
under section 4951 or 4952, regardless of  
the apportionment of tax shown on the  
return, if the amount paid by all those who  
are liable for a particular transaction is less  
than the total tax due for that transaction.  
contributions to a black lung benefit trust.  
Item C. Enter your name and address in  
the appropriate spaces.  
Item D. Enter your taxpayer identification  
number (TIN) (employer identification  
number (EIN) or social security number  
(SSN)). A filer other than the black lung  
benefit trust should not enter the trust’s  
EIN here.  
All other filers report and compute tax  
owed on Part I. Payment by a black lung  
benefit trust of any taxes owed by any  
trustee or self-dealer will result in  
additional taxes under the self-dealing  
(section 4951) and taxable expenditure  
(section 4952) provisions. Trustees and  
self-dealers should pay taxes imposed on  
them from their own funds.  
Item E. Check the “Amended return” box  
if the filer previously filed a Form 6069  
return with the IRS for a tax year and is  
now filing another return for the same tax  
year to amend the previously filed return.  
Complete the entire return (not just the  
part that changed) following the form and  
instructions for the amended year. Include  
a statement that identifies the lines and  
amounts being changed and the reason  
for each change.  
Tax payments can be made by check  
or through the Electronic Federal Tax  
Payment System (EFTPS). For more  
information about EFTPS or to enroll in  
EFTPS, visit the EFTPS website at  
EFTPS.gov, or call 800-555-4477. You  
can also get Pub. 966, Electronic Federal  
Tax Payment System: A Guide to Getting  
Started.  
Items F and G. If you checked a box on  
line (2) of Item B, enter the name on Item  
F and EIN on Item G of the black lung  
benefit trust to which the excise taxes  
being reported relate.  
Part II. Initial Taxes on  
Self-Dealing  
Items H and I. In Item H, enter the name  
and address of the person who has the  
filer's books and records. In Item I, enter  
the telephone number at which he or she  
can be reached.  
Disqualified persons and trustees who  
participate in acts of self-dealing with a  
black lung benefit trust and who have tax  
years different from the trust should use  
their own tax years to figure the initial tax  
and file the return.  
Line 3. Enter on line 3d the total initial tax  
on the self-dealer(s) computed on line 2d.  
Enter on line 3e the total initial tax on the  
trustee(s) computed on line 2e.  
Rounding Off to Whole  
Dollar Amounts  
Initial section 4951 taxes on self-deal-  
er. An initial tax of 10% of the amount  
involved is imposed for each act of  
For a Form 6069 filed by the trust.  
Do not carry amounts from Part II to Part I.  
The trust completes Part II to provide  
information on the self-dealing  
You can round off cents to whole dollars  
on your return. If you do round to whole  
dollars, you must round all amounts. To  
round, drop amounts under 50 cents and  
increase amounts from 50 to 99 cents to  
self-dealing between a disqualified person  
and a black lung benefit trust, for each  
year (or part of a year) in the taxable  
period. The tax is paid by any disqualified  
transactions, but must not pay the tax for  
which self-dealers and trustees are liable.  
-3-  
For a Form 6069 filed by a  
trustee who took part in the taxable  
expenditure and who knew that the act  
was a taxable expenditure (except for  
filed or expected to be filed by, or on  
behalf of, past or present employees for  
compensation because of disability or  
self-dealer. The filer should enter the  
amount shown on line 3d, in Part I, line 3a.  
In Part I, line 3b, indicate the percentage  
of the amount reported on line 3a  
trustees whose participation was not willful death, due to pneumoconiosis, under the  
and was due to reasonable cause) is liable Black Lung Acts.  
apportioned to the filer. Attach a statement for the tax in column (c).  
Line 2a. Enter the total amount paid  
during the year for any combination of the  
following.  
showing detail for proration of the excise  
tax on the self-dealing transactions among  
the self-dealers.  
If more than one trustee took part in the  
taxable expenditure, knowing that it was  
such an act, and participation was willful  
and not due to reasonable cause, each is  
individually liable for the entire tax in  
connection with the act. Nonetheless, the  
trustees liable for the excise tax may  
prorate the payment among themselves.  
Attach a statement showing the name of  
each trustee liable for the tax in column  
(iii) for each taxable expenditure.  
All administrative and other incidental  
expenses of operating the trust and  
processing claims against the coal mine  
operator (including legal, actuarial, and  
trustee expenses).  
For a Form 6069 filed by a trustee.  
The filer should enter the amount shown  
on line 3e, in Part I, line 4a. In Part I,  
line 4b, indicate the percentage of the  
amount reported on line 4a apportioned to  
the filer. Attach a statement showing detail  
for proration of the excise tax on  
All direct payments by the trust for  
claims against the coal mine operator.  
All payments of premiums exclusively  
for insurance to cover the coal mine  
operator’s liability for claims filed under the  
Black Lung Acts.  
self-dealing among the trustees.  
Line 4. Enter on line 4b the total initial tax  
on the trust computed on line 3b. Enter on  
line 4c the total initial tax on the trustee(s)  
computed on line 3c.  
Line 4. Corrective action. The trust and  
each self-dealer filing Form 6069 to report  
a self-dealing transaction should describe  
corrective action taken (or not taken) in  
connection with each self-dealing  
All payments of accident and health  
benefits for retired miners and their  
spouses and dependents to the extent  
allowed by section 501(c)(21)(C).  
For a Form 6069 filed by the trust.  
Enter the amount shown in line 4b, in Part  
I, line 1.  
transaction. In the case of self-dealers and  
trustees, the information provided for  
line 4 should be limited to transactions for  
which the filer incurred excise tax liability  
under section 4951.  
Line 2b. Enter the FMV of the trust’s  
assets at the beginning of the coal mine  
operator’s tax year.  
For a Form 6069 filed by a trustee.  
The filer should enter the amount shown  
on line 4c, in Part I, line 5a. In Part I,  
Line 3a. When an excess contribution is  
made to a black lung benefit trust in the  
current tax year and the trust returns part  
or all of the current year’s excess  
line 5b, indicate the percentage of the  
amount reported on line 5a apportioned to  
the filer. Attach a statement showing detail  
for the proration of the excise tax on  
Part III. Initial Taxes on  
Taxable Expenditures and  
Tax Computation  
Initial section 4952 taxes on trust. An  
initial tax of 10% of the amount of the  
expenditure is imposed on each taxable  
expenditure from the assets of a black  
lung benefit trust. The tax is paid from  
assets of the trust.  
Initial section 4952 taxes on trustee.  
When a tax is imposed on the trust for a  
taxable expenditure, any trustee who  
knowingly agreed to the expenditure must  
pay a tax of 2.5% of the amount of the  
taxable expenditure, unless such  
agreement was not willful and was due to  
reasonable cause.  
contribution in the same year, show only  
the net contribution for the year on this line  
(for example, current year’s contribution  
less current year’s excess contribution  
returned). At your request, a black lung  
benefit trust will repay excess  
taxable expenditures among the trustees.  
Line 5. Corrective action. The trust  
should describe corrective action taken (or  
not taken) in connection with each taxable  
expenditure.  
contributions (but not more than the  
excess) made to the trust for a tax year.  
The repayment is not an act of self-dealing  
or a taxable expenditure.  
Part IV. Tax on Coal Mine  
Operators Under Section  
4953  
Line 3d. Enter excess contributions  
carried over from the previous year.  
If you are a coal mine operator completing  
Form 6069 only to figure the maximum  
allowable deduction under section 192  
and do not owe tax on excess  
Line 5. Enter excess contributions carried  
over from the prior tax year that were  
returned to the contributor in the current  
tax year.  
contributions, keep this form with your  
records instead of filing it with the IRS.  
Line 1. List each taxable expenditure on  
line 1, providing the name and address of  
the recipient of cash or other property  
distributed for other than a purpose  
described in section 501(c)(21) in column  
(b); and a brief description of each  
expenditure in column (c).  
Line 7. Excess contributions entered on  
this line are carried over to the following  
tax year and treated as a contribution for  
that tax year.  
No deduction is allowed under section  
192(a) for any contribution to a trust other  
than a contribution in cash or in items in  
which the trust may invest under section  
501(c)(21)(A)(ii)(II).  
Line 8. If the amount on line 7 is greater  
than zero, multiply that amount by 0.05  
and enter the amount here and on Part I,  
line 2.  
Payments made for a particular tax  
year that are made no later than the due  
date (including extensions) of the mine  
operator’s income tax return for that tax  
year are considered to have been made  
on the last day of that tax year.  
Line 2. For each taxable expenditure,  
provide the date the expenditure was paid  
or incurred (column (b)), the amount  
(column (c)), and the name of each trustee  
liable for the excise tax (column (d)).  
Signature and Verification  
Form 6069 filed by a black lung benefit  
trust should be signed by the trustee using  
the top signature area. Form 6069 filed by:  
Line 3. For each taxable expenditure,  
multiply the amount on line 2, column (c),  
by 0.10 and enter the amount in column  
(b). The black lung benefit trust is liable for  
the excise tax shown in column (b).  
For each taxable expenditure, multiply  
the amount on line 2, column (c), by 0.025  
and enter the amount in column (c). A  
Line 1. The determination of amounts  
necessary to cover payments for claims  
made under the Black Lung Benefits Acts  
of 1977 must be based on reasonable  
actuarial assumptions. On lines 1a, 1b,  
and 1c, enter the annual amounts needed  
to fund (with level funding) all claims  
against the coal mine operator that were  
A trustee liable for the excise tax on a  
trustee’s participation in an act of  
self-dealing (section 4951) or a taxable  
expenditure (section 4952),  
A self-dealer liable for the excise tax  
under section 4951, or  
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A mine operator liable for the excise tax  
Give a copy of the return to the  
black lung benefit trust. You are required  
to give us the information. Section 6109  
requires you to provide your taxpayer  
identification number (EIN or SSN). We  
need it to ensure that you are complying  
with these laws and to allow us to figure  
and collect the right amount of tax. Failure  
to provide this information in a timely  
manner, or providing false information,  
may subject you to penalties. Routine  
uses of this information include giving it to  
the Department of Justice for civil and  
criminal litigation, and to cities, states, and  
the District of Columbia for use in the  
administration of their taxes. We may also  
disclose this information to federal and  
state agencies to enforce federal nontax  
criminal laws and to combat terrorism.  
on excess contributions under section  
4953,  
organization, in addition to the copy to be  
filed with the IRS.  
should be signed using the signature line  
below the signature line used by the black  
lung benefit trust.  
If you are signing on behalf of the black  
lung benefit trust and also because of  
personal tax liability, you must file two  
Forms 6069.  
For a corporation (or an association),  
the form may be signed by one of the  
following: president, vice president,  
treasurer, assistant treasurer, chief  
accounting officer, or other corporate  
officer (such as tax officer). For a  
partnership, the form may be signed by a  
partner or partners authorized to sign the  
partnership return.  
Any paid preparer whose  
identifying number must be listed  
!
CAUTION  
on Form 6069 can apply for and  
obtain a PTIN. You can apply for a PTIN  
online or by filing Form W-12, IRS Paid  
Preparer Tax Identification Number (PTIN)  
Application and Renewal. For more  
information about applying for a PTIN  
online, visit the IRS website at IRS.gov/  
PTIN.  
Paid Preparer  
Authorization  
On the “Sign Here” line, check “Yes” if the  
IRS can contact the paid preparer who  
signed the return to discuss the return.  
This authorization applies only to the  
individual whose signature appears in the  
Paid Preparer Use Only section of Form  
6069. It doesn't apply to the firm, if any,  
shown in that section.  
You are not required to provide the  
information requested on a form that is  
subject to the Paperwork Reduction Act  
unless the form displays a valid OMB  
control number. Books or records relating  
to a form or its instructions must be  
retained as long as their contents may  
become material in the administration of  
any Internal Revenue law. Generally, tax  
returns and return information are  
confidential, as required by Code section  
6103.  
If the return is filed on behalf of a trust,  
the authorized trustee(s) must sign it.  
A receiver, trustee, or assignee  
required to file any return on behalf of an  
individual, trust, estate, partnership,  
association, company, or corporation must  
sign the Form 6069 filed for these  
By checking the “Yes” box, the  
organization is authorizing the IRS to  
contact the paid preparer to answer any  
questions that arise during the processing  
of the return. The organization is also  
authorizing the paid preparer to:  
taxpayers. Also, a person with a valid  
power of attorney may sign for the section  
501(c)(21) trust, trustee, self-dealer, or  
mine operator. Include a copy of the  
power of attorney with the return.  
The time needed to complete and file  
this form will vary depending on individual  
circumstances. The estimated average  
time is:  
Give the IRS any information missing  
from the return;  
Call the IRS for information about  
Attachments  
If you need more space, attach separate  
sheets showing the same information in  
the same order as on the printed form.  
Show the totals on the printed form.  
processing the return; and  
Respond to certain IRS notices about  
Recordkeeping. . . . .  
7 hr., 10 min.  
1 hr., 17 min.  
1 hr., 27 min.  
math errors, offsets, and return  
preparation.  
Learning about the  
law or the form . . .  
On each sheet, enter the name and TIN  
of the person or entity filing Form 6069.  
Also include the name and EIN of the  
section 501(c)(21) black lung trust, and, if  
applicable, the name and TIN of the  
trustee, self-dealer, or mine operator on  
each sheet. Use sheets that are the same  
size as the form and indicate clearly the  
line of the paper form to which the  
information relates.  
The organization isn't authorizing the  
paid preparer to bind the organization to  
anything or otherwise represent the  
organization before the IRS.  
Preparing the  
form . . . . . . . . . . .  
Copying,  
The authorization will automatically end  
no later than the due date (excluding  
extensions) for filing of the Form 6069 for  
the next tax year. If the organization wants  
to expand the paid preparer's  
assembling, and  
sending the form  
to the IRS . . . . . . .  
16 min.  
authorization or revoke it before it ends,  
see Pub. 947, Practice Before the IRS and  
Power of Attorney.  
Paid Preparer  
If you have comments concerning the  
accuracy of these time estimates or  
Generally, anyone who is paid to prepare  
the return must sign the return and fill in  
the other blanks in the Paid Preparer Use  
Only area. An employee of the filing  
organization isn't a paid preparer.  
suggestions for making this form simpler,  
we would be happy to hear from you. You  
can send us comments through IRS.gov/  
FormComments. Or you can write to the  
Internal Revenue Service, Tax Forms and  
Publications, 1111 Constitution Ave. NW,  
IR-6526, Washington, DC 20224. Don’t  
send the tax form to this office. Instead,  
see When and Where To File, earlier.  
Check “No” if the IRS should contact  
the organization listed on the first page of  
the Form 6069 rather than the paid  
preparer.  
The paid preparer must:  
Sign the return in the space provided  
Privacy Act and Paperwork Reduction  
Act Notice. We ask for the information on  
this form to carry out the Internal Revenue  
laws of the United States. Section 4953  
imposes a tax on excess contributions to a  
for the preparer's signature;  
Enter the preparer information;  
Enter the preparer tax identification  
number (PTIN); and  
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