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Federal Free Printable Form 6069 (Rev. December 2021) for 2022 Federal Return of Excise Tax on Excess Contributions to Black Lung Benefit Trust Under Section 4953 and Computation of Section 192 Deduction

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Return of Excise Tax on Excess Contributions to Black Lung Benefit Trust Under Section 4953 and Computation of Section 192 Deduction
Form 6069 (Rev. December 2021)

6069 Form (Rev. December 2021) 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 Filer is: (1) Section 501(c)(21) Trust (2) Disqualified person; Trustee; Mine operator (see instructions) C Name of mine operator, trust, or person subject to tax Number, street, and room or suite no. (or P.O. box number) City or town, state, and ZIP code , and ending D EIN or SSN E Address change Amended return 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 9 Tax and Payment Initial tax on the trust under section 4952(a)(1) (Part III, line 4b) . . . . . . . . . . . . . 1 Tax on mine operator under section 4953 (Part IV, line 8) . . . . . . . . . . . . . . . 2 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 % 3c 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 % 4c 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 % 5c 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 . . . . . . . . . 6 Total payments, including amount paid with Form 8868 (see instructions) . . . . . . . . . . 7 Tax due. If line 6 is larger than line 7, subtract line 7 from line 6 and enter amount owed . . . . ▶ 8 Overpayment. If line 6 is smaller than line 7, subtract line 6 from line 7 and enter the amount overpaid. This is your refund . . . . . . . . . . . . . . . . . . . . . . . ▶ 9 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 12145E Form 6069 (Rev. 12-2021) Form 6069 (Rev. 12-2021) Part II 1 Page 2 Initial Taxes on Self-Dealing (Section 4951) Acts of self-dealing (a) Act number (b) Date of act (c) Description of act (see instructions) (1) (2) 2 Computation of initial tax on self-dealing disqualified person or trustee (a) Act number (b) Self-dealer(s) (d) Initial tax on self-dealer (10% (0.10) of col. (c)) (see instructions) (c) Amount involved (e) Tax on trustee, if applicable (2.5% (0.025) of col. (c)) (see instructions) (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. (b) Has corrective (a) Act action been taken? number Yes No (c) FMV of amount recovered (1) (2) Part III 1 Initial Taxes on Taxable Expenditures and Tax Computation (Section 4952) Taxable expenditures (a) Item number (b) Name and address of recipient (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 number (b) Date paid or incurred (c) Amount (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) (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. 4 5 (b) Has corrective (a) Act action been taken? number Yes No (c) FMV of amount recovered (1) (2) Part IV 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: 1 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 Treasury . . . . . . . . . . . . . . . . . . . . . d Enter the smaller of line 1a or 1b e Enter the larger of line 1c or 1d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . of . . . the . . . . . 1a 1b 1c 1d . . . . . . . . 1e Form 6069 (Rev. 12-2021) Form 6069 (Rev. 12-2021) Part IV 2a Page Enter the amount necessary to carry out section 501(c)(21)(A) purposes for the tax year . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . . Amount that current year’s contributions are less than the maximum amount 4 deductible. Subtract line 3a from line 3b. If zero or less, enter -0- . . . . 4 Amount of previous year’s excess contributions that were returned to the 5 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 3 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) 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 . . . . . . . . . . . . . . . . 2c . . . . 3e . . . . . . . . . . . . 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 (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 Signature of trustee Signature (and organization or entity name, if applicable) of trustee, self-dealer, or mine operator Date May the IRS discuss this return with the preparer shown below? See instructions Paid Preparer Use Only Print/Type preparer’s name Firm’s name ▶ Firm’s address ▶ Date Title Preparer’s signature . . . . . . Date . . . . Yes . Check if self-employed No PTIN Firm’s EIN ▶ Phone no. Form 6069 (Rev. 12-2021)
Extracted from PDF file 2021-federal-form-6069.pdf, last modified December 1969

More about the Federal Form 6069 Other TY 2021

We last updated the Return of Excise Tax on Excess Contributions to Black Lung Benefit Trust Under Section 4953 and Computation of Section 192 Deduction in January 2022, so this is the latest version of Form 6069, fully updated for tax year 2021. You can download or print current or past-year PDFs of Form 6069 directly from TaxFormFinder. You can print other Federal tax forms here.

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Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 6069 from the Internal Revenue Service in January 2022.

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Historical Past-Year Versions of Federal Form 6069

We have a total of nine past-year versions of Form 6069 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2021 Form 6069

Form 6069 (Rev. December 2021)

2020 Form 6069

Form 6069 (Rev. February 2012)

2019 Form 6069

Form 6069 (Rev. February 2012)

2018 Form 6069

Form 6069 (Rev. February 2012)

2017 Form 6069

Form 6069 (Rev. February 2012)

2016 Form 6069

Form 6069 (Rev. February 2012)

Return of Excise Tax on Excess Contributions to Black Lung Benefit Trust Under Section 4953 and Computation of Section 192 Deduction 2015 Form 6069

Form 6069 (Rev. February 2012)

Return of Excise Tax on Excess Contributions to Black Lung Benefit Trust Under Section 4953 and Computation of Section 192 Deduction 2012 Form 6069

Form 6069 (Rev. February 2012)

Return of Excise Tax on Excess Contributions to Black Lung Benefit Trust Under Section 4953 and Computation of Section 192 Deduction 2011 Form 6069

Form 6069 (Rev. February 2012)


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