Forms, Schedules, and Instructions for U.S. Tax-Exempt Returns

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Instructions for Form 6069
(Rev. December 2025)

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.

Future Developments

For the latest information about developments related to Form
6069 and its instructions, such as legislation enacted after they
were published, go to IRS.gov/Form6069.

Electronic payments. If you have access to U.S. banking
services or electronic payment systems, you should use direct
deposit for any refunds. The IRS recommends paying
electronically whenever possible.
Direct deposit. We have added direct deposit fields on lines
9b, 9c, and 9d. If there is an overpayment on Part I, line 9a, enter
your direct deposit information on Part I, lines 9b, 9c, and 9d.
See Part I, Lines 9a through 9d under Specific Instructions, later,
for more information.
Making a payment. If there is a balance due on line 8, go to
IRS.gov/payments for information on how to make a payment.
See the instructions Line 8 for more information.

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 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 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,
respectively, of Form 6069.
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) 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.

Who Must File

• Any person who is a disqualified person with respect to a

black lung benefit trust and has incurred liability for the excise tax
on self-dealing transactions under section 4951.
• 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).

Sep 25, 2025

!

CAUTION

A coal mine operator should not file Form 6069 if the
information entered in Part IV indicates that no excess
contributions were made.

Which Parts To Complete
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.
• Complete Parts II and III first, providing complete information
about the self-dealing and taxable expenditure transactions and
showing tax computations.
• Complete Part I, line 1, only. Do not include taxes that must be
paid by the trustee or a self-dealer on any other line in Part I.
When filer is a self-dealer. A self-dealer liable for initial taxes
under section 4951 completes Part II, then Part I.
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.
When filer is a coal mine operator. A coal mine operator
completes Part III to figure the amount of its allowable
contributions for the tax year. The coal mine operator completes
Part I and files Form 6069 only if contributions exceed the
allowed contribution amount.

When and Where To File

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:
Internal Revenue Service Center
333 W. Pershing Road
Kansas City, MO 64108
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.

Accounting Methods

Use the accounting method regularly used in keeping your books
and records.

Accounting Periods

Complete the return on the basis of your established accounting
period. If you do not have an established accounting period, use
the calendar year.

Penalties and Interest

There are penalties for late filing, willful failure to file, and for filing
fraudulent returns and statements. See sections 6651, 7203,

Instructions for Form 6069 (Rev. 12-2025) Catalog Number 74987O
Department of the Treasury Internal Revenue Service www.irs.gov

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What’s New

• Any black lung benefit trust that has incurred liability for the
excise tax on taxable expenditures (under section 4952).
• 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.

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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.

Definitions

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
indicated, the term “trust” as used in these 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.

Self-dealing. For purposes of section 4951, the term
“self-dealing” means any direct or indirect:
• 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 credit between such a
trust and a disqualified person;
• 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
• Transfers to, or use by or for the benefit of, a disqualified
person of the income or assets of such a trust.
Special rules. For purposes of 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;
• 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;
• The furnishing of goods, services, or 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
• The payment of compensation (and the 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.
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);
2. The date on which the tax imposed by section 4951(a)(1)
is assessed; or
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, the greater of the amount of money and the
fair market value (FMV) of the other property given or the amount
2

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.
Disqualified person. The term “disqualified person” means, for
a trust described in section 501(c)(21), a person who is:
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 a corporation,
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;
4. An officer, director, or employee of 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.
For purposes of items 3a and 6 above, indirect stockholdings
are taken into account if they would be taken into 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.
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.

Taxable Expenditures (Section 4952)
Taxable expenditure. For purposes of section 4952, the term
“taxable 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.
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

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Self-Dealing (Section 4951)

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:
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.

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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.

drop amounts under 50 cents and increase amounts from 50 to
99 cents to the next dollar. For example, $1.39 becomes $1 and
$2.50 becomes $3.

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
2. The date on which the tax imposed by section 4952(a)(1)
is assessed.

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.

Specific Instructions
Item A. Fill in the spaces to show the calendar year or fiscal
year of the accounting period you are reporting.
A black lung benefit trust filing to report taxable expenditures
(section 4952) should enter the calendar or fiscal year of the
trust.
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.
Item B. Check box (1) if you are a black lung benefit trust liable
for the section 4952 tax on taxable expenditures.
Check the appropriate box(es) on line (2) if you are one or
more of the following.
• A disqualified person liable for the section 4951 excise tax on
self-dealing.
• A trustee of a black lung benefit trust 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).
• A coal mine operator liable for the section 4953 excise tax on
excess 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.
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.
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.
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.

Rounding Off to Whole Dollar
Amounts

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,

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.
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.
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 themselves. The IRS may assess a deficiency against
one or more 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.
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.

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Items A Through I

Part I. Tax and Payment

Line 8. You must pay the tax in full when the return is filed.

Making a Payment

All payments made to the federal government are to be
processed electronically. Go to IRS.gov/Payments for more
detailed information on using any of the payment options below.
If you qualify for an exception, an alternative payment option
(check, money order, or cash) may be permitted. See
Non-electronic payment option exceptions, next, for more
information.
• IRS Direct Pay
• Debit card, credit card, or digital wallet
• Electronic Funds Withdrawal (EFW)
• Electronic Federal Tax Payment System (EFTPS)
• Same-day wire
Non-electronic payment option exceptions. If you qualify for
one of the exceptions below, a check, money order, or cash may
still be permitted as a payment option.
1. Individuals who do not have access to banking services
or electronic payment systems.
2. Certain emergency payments where electronic
disbursement would cause undue hardship, as contemplated in
31 CFR Part 208.
3. National security- or law enforcement-related activities
where non-EFT transactions are necessary or desirable.
4. Other circumstances as determined by the Secretary of
the Treasury, as reflected in regulations or other guidance.
Note: If you don't qualify for one of the exceptions above, you
are to use an electronic payment option to make a payment. If
you do qualify for an exception above, see Paying by check or
money order or Paying with cash, below for additional payment
options.
Paying by check or money order. If you pay by check or
money order:
3

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• Make the check payable to “United States Treasury.”
• Write the SSN or EIN and “Form 6069” on the check to assist

us in posting it to the proper account.
Paying with cash. You may be able to pay your balance due
with cash at a participating retail store. See IRS.gov/
PayYourTaxesWithCash.
Lines 9a through 9d. To elect direct deposit of an overpayment
shown on line 9a, you must complete lines 9b, 9c, and 9d.

Part II. Initial Taxes on 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.

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 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).
Line 2. For each act of self-dealing listed on line 1, provide the
following information.
• In column (b), enter the names of all disqualified persons who
took part in the acts of self-dealing listed on line 1.
• 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.
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.
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 transactions, but must not pay the
tax for which self-dealers and trustees are liable.
For a Form 6069 filed by a 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
4

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 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.

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.
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 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)).
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
trustee who took part in the taxable expenditure and who knew
that the act was a taxable expenditure (except for trustees whose
participation was not willful and was due to reasonable cause) is
liable for the tax in column (c).
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.
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.
For a Form 6069 filed by the trust. Enter the amount shown
in line 4b, in Part I, line 1.
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 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 taxable expenditures among the
trustees.

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Initial section 4951 taxes on self-dealer. An initial tax of 10%
of the amount involved is imposed for each act of 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 person (other than a trustee acting only as
such) who participated in the act of self-dealing.

line 3a apportioned to the filer. Attach a statement showing detail
for proration of the excise tax on the self-dealing transactions
among the self-dealers.
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 self-dealing among the trustees.

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Line 5. Corrective action. The trust should describe corrective
action taken (or not taken) in connection with each taxable
expenditure.

Part IV. Tax on Coal Mine Operators
Under Section 4953

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 contributions, keep this form with your
records instead of filing it with the IRS.
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 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 filed or expected to be filed by, or on behalf of, past or
present employees for compensation because of disability or
death, due to pneumoconiosis, under the Black Lung Acts.
Line 2a. Enter the total amount paid during the year for any
combination of the following.
• All administrative and other incidental expenses of operating
the trust and processing claims against the coal mine operator
(including legal, actuarial, and trustee expenses).
• 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.
• 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).
Line 2b. Enter the FMV of the trust’s assets at the beginning of
the coal mine operator’s tax year.
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 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 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.
Line 3d. Enter excess contributions carried over from the
previous year.
Line 5. Enter excess contributions carried over from the prior
tax year that were returned to the contributor in the current tax
year.
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.
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.

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:

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.
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
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.

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.
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.

Paid Preparer

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.
The paid preparer must:

• Sign the return in the space provided for the preparer's

signature;
• Enter the preparer information;
• Enter the preparer tax identification number (PTIN); and
• Give a copy of the return to the organization, in addition to the
copy to be filed with the IRS.
Any paid preparer whose identifying number must be
listed on Form 6069 can apply for and obtain a PTIN.
CAUTION 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.
By checking the “Yes” box, the organization is authorizing the
IRS to contact the paid preparer to answer any questions that
5

DRAFT

DRAFT

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.

• 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
• A mine operator liable for the excise tax on excess
contributions under section 4953,
should be signed using the signature line below the signature
line used by the black lung benefit trust.

TREASURY/IRS AND OMB USE ONLY DRAFT

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 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.

6

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.
The time needed to complete and file this form will vary
depending on individual circumstances. The estimated average
time is:
Recordkeeping . . . . . . . . . . . . . .

7 hr., 10 min.

Learning about the law or the
form . . . . . . . . . . . . . . . . . . . .

1 hr., 17 min.

Preparing the form . . . . . . . . . . .

1 hr., 27 min.

Copying, assembling, and
sending the form to the IRS . .

16 min.

If you have comments concerning the accuracy of these time
estimates or 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.

DRAFT

DRAFT

arise during the processing of the return. The organization is also
authorizing the paid preparer to:
• Give the IRS any information missing from the return;
• Call the IRS for information about processing the return; and
• Respond to certain IRS notices about math errors, offsets,
and return preparation.
The organization isn't authorizing the paid preparer to bind
the organization to anything or otherwise represent the
organization before the IRS.
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 authorization or revoke it before it ends, see Pub. 947,
Practice Before the IRS and Power of Attorney.
Check “No” if the IRS should contact the organization listed
on the first page of the Form 6069 rather than the paid preparer.