6069 Return of Certain Excise Taxes on Mine Operators, Black

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TREASURY/IRS AND OMB USE ONLY DRAFT
Form

6069

(Rev. December 2025)
Department of the Treasury
Internal Revenue Service

Return of Certain Excise Taxes on Mine Operators, Black Lung
Trusts, and Other Persons Under Sections 4951, 4952, and 4953

OMB No. 1545-0047

NOT Open for
Public Inspection

Go to www.irs.gov/Form6069 for instructions and the latest information.

A
B

For calendar year
or other tax year beginning
, and ending
Filer is:
Section 501(c)(21) Trust
(1)
Disqualified person;
Trustee;
Mine operator (see instructions)
(2)
C Name of mine operator, trust, or person subject to tax
D EIN or SSN
Number, street, and room or suite no. (or P.O. box number)
State

Address change
Amended return

ZIP code

F Name of related section 501(c)(21) Trust (if the trust is not the filer)

G EIN of the related trust

H Books and records are in care of:

I Telephone no.

Part I
1
2
3a
b
c
4a
b
c
5a
b
c
6
7
8
9a

Tax and Payment

Initial tax on the trust under section 4952(a)(1) (Part III, line 4b) . . . . . . . . . . . . .
Tax on mine operator under section 4953 (Part IV, line 8) . . . . . . . . . . . . . . .
Initial tax on self-dealer under section 4951(a)(1) (Part II, line 3d) . . . . .
3a
Self-dealer’s ratable share of liability (see instructions) . . . . . . . .
3b
%
Filing self-dealer’s liability. Multiply line 3a by percentage share reported on line 3b . . . . . .
Initial tax on trustee under section 4951(a)(2) (Part II, line 3e) . . . . . .
4a
Filing trustee’s ratable share of liability (see instructions) . . . . . . .
4b
%
Filing trustee’s liability. Multiply line 4a by percentage share reported on line 4b
. . . . . . .
Initial tax on the trustee under section 4952(a)(2) (Part III, line 4c)
. . . .
5a
Filing trustee’s ratable share of liability (see instructions) . . . . . . .
5b
%
Filing trustee’s liability. Multiply line 5a by percentage share reported on line 5b
. . . . . . .
Total tax. Enter the amount from line 1, or the sum of lines 2, 3c, 4c, and 5c
. . . . . . . .
Total payments, including amount paid with Form 8868 (see instructions) . . . . . . . . . .
Tax due. If line 6 is larger than line 7, subtract line 7 from line 6 and enter amount owed. For details
on how to pay, go to www.irs.gov/Payments or see the instructions
. . . . . . . . . . .
Overpayment. If line 6 is smaller than line 7, subtract line 6 from line 7 and enter the amount
overpaid. Complete lines 9b, 9c, and 9d
. . . . . . . . . . . . . . . . . . . .

b Routing number
d Account number

c

Type:

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Checking
Cat. No. 12145E

1
2

3c

4c

5c
6
7
8
9a

Savings
Form 6069 (Rev. 12-2025) Created 5/2/25

DRAFT — DO NOT FILE

DRAFT — DO NOT FILE

City or town

E

TREASURY/IRS AND OMB USE ONLY DRAFT
Page 2

Form 6069 (Rev. 12-2025)

Part II

Initial Taxes on Self-Dealing (Section 4951)

1
Acts of self-dealing
(a) Act
(b) Date
number
of act

(c) Description of act
(see instructions)

(1)
(2)
2
Computation of initial tax on self-dealing disqualified person or trustee
(d) Initial tax on self-dealer
(a) Act
(b) Self-dealer(s)
(c) Amount involved
(10% (0.10) of col. (c))
number
(see instructions)

(e) Tax on trustee, if applicable
(2.5% (0.025) of col. (c))
(see instructions)

(b) Has corrective
(a) Act
action been taken?
number
Yes
No
(1)
(2)

Part III

(c) FMV of amount recovered

Initial Taxes on Taxable Expenditures and Tax Computation (Section 4952)

1
Taxable expenditures
(a) Item
(b) Name and address of recipient
number

(c) Description of expenditure and purposes for which made

(1)
(2)
2
Taxable expenditures by section 501(c)(21) Trust (section 4952(a))
(a) Item
(b) Date paid or incurred
(c) Amount
number

(d) Trustees

(1)
(2)
3
Computation of initial tax (sections 4952(a)(1) and (2))
(a) Item
number

(b) Tax imposed on section 501(c)(21) Trust
(10% (0.10) of line 2, col. (c))
(see instructions)

(c) Tax imposed on Trustee
(2.5% (0.025) of line 2, col. (c))
(see instructions)

4
5

(1)
(2)
Totals
Corrective action. Attach a detailed statement to describe corrective action taken or to explain why corrective action has not
been taken. See instructions.

(b) Has corrective
(a) Act
action been taken?
number
Yes
No
(1)
(2)

Part IV
1

(c) FMV of amount recovered

Tax on Coal Mine Operators Under Section 4953. Computation of Section 4953 Tax by the Person
Making Excess Contributions Under Section 192 to a Section 501(c)(21) Trust (see instructions)

Enter the amount necessary to fund (with level funding) the remaining unfunded liability for claims filed
or expected to be filed by, or on behalf of, past or present employees of the operator based on:
a The average remaining working life of miners currently employed . . .
b 10 tax years . . . . . . . . . . . . . . . . . . . . .
c Any other funding period prescribed or approved by the Secretary
the Treasury . . . . . . . . . . . . . . . . . . . . .

.
.
of
.

d Enter the smaller of line 1a or 1b
e Enter the larger of line 1c or 1d .

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1a
1b
1c
1d
. . .

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1e
Form

6069 (Rev. 12-2025)

DRAFT — DO NOT FILE

DRAFT — DO NOT FILE

(1)
(2)
3
Totals . . . . . . . . . . . . . . . . .
4
Corrective action. Attach a detailed statement to describe corrective action taken or to explain why corrective action has not
been taken. See instructions.

TREASURY/IRS AND OMB USE ONLY DRAFT
Page 3

Form 6069 (Rev. 12-2025)

Part IV
2a

Enter the amount necessary to carry out section 501(c)(21)(A) purposes for the
tax year . . . . . . . . . . . . . . . . . . . . . . .
Enter the fair market value of the trust’s assets. See instructions
. .
Subtract line 2b from line 2a. If zero or less, enter -0- . . . . . .
Contributions made to section 501(c)(21) Trust for operator’s tax year .
Operator’s maximum allowable deduction under section 192 for tax
Enter the larger of line 1e or line 2c . . . . . . . . . . . .

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2c

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3e

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6
7
8

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and
statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other
than taxpayer) is based on all information of which preparer has any knowledge.

Signature of trustee

Date

Title

Signature (and organization or entity name, if applicable) of trustee, self-dealer, or mine operator

Date

Signature (and organization or entity name, if applicable) of trustee, self-dealer, or mine operator

Date

Signature (and organization or entity name, if applicable) of trustee, self-dealer, or mine operator

Date

Signature (and organization or entity name, if applicable) of trustee, self-dealer, or mine operator

Date

Sign
Here

Paid
Preparer
Use Only

May the IRS discuss this return with the preparer shown below? See instructions .
Preparer’s name
Preparer’s signature
Date
Firm’s name
Firm’s address

.

.

.
Yes
Check
if PTIN
self-employed
Firm’s EIN
Phone no.

No

Form 6069 (Rev. 12-2025)

DRAFT — DO NOT FILE

2a
. .
2b
. . . . . .
. .
3a
year.
. .
3b
c Subtract line 3b from line 3a. If zero or less, enter -0- . . . . . . . .
3c
d Excess contributions carried over from the preceding tax year . . . . .
3d
e Total. Add lines 3c and 3d . . . . . . . . . . . . . . . . . . . . .
4
Amount that current year’s contributions are less than the maximum amount
deductible. Subtract line 3a from line 3b. If zero or less, enter -0- . . . .
4
5
Amount of previous year’s excess contributions that were returned to the
contributor during the current tax year . . . . . . . . . . . . .
5
6
Total. Add lines 4 and 5 . . . . . . . . . . . . . . . . . . . . . .
7
Excess contributions for current year. Subtract line 6 from line 3e. If zero or less, enter -08
Tax imposed on mine operator. Enter 5% (0.05) of line 7 here and in Part I, line 2 . . .

b
c
3a
b

DRAFT — DO NOT FILE

Tax on Coal Mine Operators Under Section 4953. Computation of Section 4953 Tax by the Person
Making Excess Contributions Under Section 192 to a Section 501(c)(21) Trust (see instructions)
(continued)