1213 Form 990-BL (PDF) — verbatim text

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f990bl.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

Form 990-BL¶

(Rev. December 2013)

Department of the Treasury Internal Revenue Service

Exceptions & meaning →

Information and Initial Excise Tax Return for Black¶

Lung Benefit Trusts and Certain Related Persons¶

OMB No. 1545-0049

Under section 501(c)(21) of the Internal Revenue Code.

Information about Form 990-BL and its instructions is available at www.irs.gov/form990bl .

For calendar year , or fiscal year beginning , , and ending , Name of trust Employer identification number (EIN) of trust

Name of other person filing return Social security number (SSN) or EIN of other filer

Number, street, and room or suite no. (If a P.O. box, see instructions.) If application pending, check here . . ^▶

If address changed, check here . . . ^▶ City or town, state or province, country, ZIP or foreign postal code FMV of assets at beginning of operator’s tax year . ^▶

Return filed by (check box that applies): Trust (Open for public inspection—other than Part IV) Trustee (Not open for public inspection)

The books are in care of ^▶ Telephone number ^▶

Located at ^▶

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 officer or trustee) is based on all information of which preparer has any knowledge.

Sign Here	▲▲ Signature of officer or trustee Date Type or print name and title
Paid Preparer Use Only	Paid Preparer Use Only	Print/Type preparer’s name	Preparer's signature	Date	Check if self-employed	PTIN	PTIN	PTIN	PTIN	PTIN
Paid Preparer Use Only	Paid Preparer Use Only	Firm’s name▶	Firm’s name▶	Firm’s name▶	Firm's EIN▶	Firm's EIN▶	Firm's EIN▶	Firm's EIN▶	Firm's EIN▶	Firm's EIN▶
Paid Preparer Use Only	Paid Preparer Use Only	Firm's address▶	Firm's address▶	Firm's address▶	Phone no.	Phone no.	Phone no.	Phone no.	Phone no.	Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) . . . . . . . . . . .	May the IRS discuss this return with the preparer shown above? (see instructions) . . . . . . . . . . .	May the IRS discuss this return with the preparer shown above? (see instructions) . . . . . . . . . . .	May the IRS discuss this return with the preparer shown above? (see instructions) . . . . . . . . . . .	May the IRS discuss this return with the preparer shown above? (see instructions) . . . . . . . . . . .	May the IRS discuss this return with the preparer shown above? (see instructions) . . . . . . . . . . .	May the IRS discuss this return with the preparer shown above? (see instructions) . . . . . . . . . . .		Yes		No

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 10315Y Form 990-BL (Rev. 12-2013)

Form 990-BL (Rev. 12-2013) Page 2

(e) Compensation

(If not paid, enter zero.)

(c) Contributions to employee benefit

plans

(d) Expense account, other

allowances

(a) Name and Address

(b) Title and time devoted to position

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ^▶

Part IV Statement With Respect to Contributors, etc. — (Not open for public inspection)

1 Persons who contributed $5,000 or more in the taxable year (if more space is needed, attach schedule):

Name Address

2 During the period covered by this return did the trust receive any contributions in excess of the maximum allowable deduction for the contributor under section 192? . . . . . . . . . . . . . . . . . .

Yes No

Form 990-BL (Rev. 12-2013)

Form 990-BL (Rev. 12-2013) Page 3 Schedule A—Initial Excise Taxes on Black Lung Benefit Trusts and Certain Related Persons

Under sections 4951 and 4952 of the Internal Revenue Code

NOT OPEN FOR PUBLIC INSPECTION

For the calendar year , or fiscal year beginning , , and ending , Name of trust/person filing return (see instructions) EIN or SSN of filer (see instructions)

Name of related section 501(c)(21) trust (if applicable)

Return filed by (see instructions, check box that applies): Trust Trustee

Disqualified person Part I Initial Taxes on Self-dealing (Section 4951) and Taxable Expenditures (Section 4952)

SECTION A—Acts of Self-dealing and Tax Computation (Section 4951)

(a) Act (b) Date of act (c) Description of act number

1 2 3 4

(d) Names of disqualified persons liable for tax (e) Names of trustees liable for tax

(g) Initial tax on self-dealing disqualified person (f) Amount involved in act

(10% of column (f))

Total (add lines 1 through 4, columns (g) and (h) ) . . . . . . ^▶

(h) Tax on trustee (if applicable)

(2½% of column (f))

SECTION B—Taxable Expenditures and Tax Computation (Section 4952)

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