2022-09-15T09:42:28-05:00 2021-10-31 420714325 RSM US LLP 117 E MAIN ST SUITE 210 GALESBURG IL 61401 990 2020-11-01 367742028 PLAN A HEALTH CARE PLAN TRUST PLAN 3093431550 285 S FARNHAM ST GALESBURG IL 61401 RONALD WILSON TRUSTEE 3093431550 2022-09-10 1 RONALD WILSON XXX-XX-XXXX MICHAEL BASS P00458970 3093428026 2022-09-08 2 AAL1 IAL1 2020 2023-04-26 12:10:37Z RONALD WILSON 285 S FARNHAM ST GALESBURG IL 61401 9148084 0 X N/A X 2019 IL TO PROVIDE MEDICAL, SHORT-TERM DISABILITY & DEATH BENEFITS FOR ELIGIBLE EMPLOYEES & DEPENDENTS. 1 1 0 1 0 0 0 0 10560336 9147731 0 353 0 0 10560336 9148084 0 0 9043901 7059879 0 0 0 0 0 1822994 1644513 10866895 8704392 -306559 443692 4319082 4594498 1074089 901485 3244993 3693013 X THE PLAN IS A SELF-INSURED BENEFIT PROGRAM FUNDED BY THE EMPLOYERS AND PARTICIPANTS WITHIN THE PLAN. PARTICIPANTS IN THE PLAN ARE CURRENT AND FORMER EMPLOYEES OF THE FOLLOWING SPONSORS: COMMUNITY LIVING OPTIONS, INC., FRANCES HOUSE, INC., UNLIMITED DEVELOPMENT, INC., ACHIEVEMENT UNLIMITED, INC., PINNACLE OPPORTUNITIES, INC., PIONEER CONCEPTS, INC., RESIDENTIAL ALTERNATIVES OF ILLINOIS, INC., DESERT HEALTH CARE FACILITIES, INC., AND FLORIDA LIVING OPTIONS, INC. PLAN ASSETS ARE HELD IN A VOLUNTARY EMPLOYEES' BENEFIT ASSOCIATION (VEBA) TRUST. THE PLAN IS SUBJECT TO THE PROVISIONS OF THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA), AS AMENDED. 0 0 THE PURPOSE OF THE PLAN IS TO PROVIDE MEDICAL, SHORT-TERM DISABILITY, AND DEATH BENEFITS FOR ELIGIBLE EMPLOYEES AND THEIR DEPENDENTS THAT VOLUNTARILY ELECT TO PARTICIPATE IN THE PLAN. 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 1 X 0 0 0 0 0 0 0 0 0 0 0 X 1 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 X RON WILSON RFMS INC 3093431550 285 SOUTH FARNHAM GALESBURG IL 61401 X X RONALD WILSON TRUSTEE 1.00 X 0 0 0 0 0 0 0 0 0 0 RSM US LLP 331 W THIRD ST STE 200 DAVENPORT IA 52801 ACCOUNTING SERVICES 120435 1 X PLAN CONTRIBUTIONS 900001 9147731 9147731 9147731 353 353 9148084 9147731 0 353 7059879 35982 139404 1038537 ADMINISTRATIVE EXPENSES 430590 8704392 0 10838 405806 186962 346797 3913276 4049901 4319082 4594498 146268 134726 927821 766759 1074089 901485 X 0 0 0 0 3244993 3693013 3244993 3693013 4319082 4594498 X 443692 -5276 9604 X X 0 1 X 1 0 0 DUE FROM RFMS INC MEDICAL BENEFIT TRUST 4049901 4049901 BENEFITS PAYABLE 766759 766759 X 9142197 5276 5276 9136921 11163 11163 9148084 8863895 161062 161062 8702833 1559 1559 8704392 PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE PLAN MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE PLAN AND RECOGNIZE A TAX LIABILITY (OR ASSET) IF IT HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD BE SUSTAINED UPON EXAMINATION. MANAGEMENT HAS EVALUATED THE PLAN'S TAX POSITIONS AND CONCLUDED THAT THE PLAN HAS MAINTAINED ITS TAX EXEMPT STATUS AND HAS TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENT TO THE FINANCIAL STATEMENTS. THEREFORE, NO PROVISION OR LIABILITY FOR INCOME TAXES HAS BEEN INCLUDED IN THE FINANCIAL STATEMENTS. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. PART XI, LINE 4B - OTHER ADJUSTMENTS: REVENUE REPORTED ON RFMS MEDICAL BENEFT PLAN TRUST FORM 990 11,163. PART XII, LINE 2D - OTHER ADJUSTMENTS: DECREASE IN ESTIMATED OBLIGATIONS FOR CLAIMS INCURRED BUT NOT REPORTED 161,062. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES REPORTED ON RFMS MEDICAL BENEFT PLAN TRUST FORM 990 1,559. COMMUNITY LIVING OPTIONS INC (CLO) CLO, INC. IS THE SPONSOR OF PLAN A HEALTH CARE PLAN TRUST. 701750 PREMIUMS WERE PAID BY COMMUNITY LIVING OPTIONS, INC. IN THE AMOUNT OF $928,168 TO THE PLAN A HEALTH CARE PLAN TRUST FOR THE FISCAL YEAR ENDING OCTOBER 31, 2020. THE PREMIUM AMOUNT FOR COMMUNITY LIVING OPTIONS, INC. PARTICIPANTS IS THE SAME AS THAT CHARGED TO ALL OTHER PARTICIPANTS IN THE PLAN. COMMUNITY LIVING OPTIONS, INC. RECEIVES NO MONEY FROM THE PLAN A HEALTH CARE PLAN TRUST. RONALD WILSON, THE TRUSTEE OF THE PLAN A HEALTH CARE PLAN TRUST IS THE CHIEF FINANCIAL OFFICER OF COMMUNITY LIVING OPTIONS, INC. THE PLAN A HEALTH CARE PLAN TRUST TRUST PAYS NO COMPENSATION TO THE TRUSTEE OR TO COMMUNITY LIVING OPTIONS, INC. 0 FORM 990, PART V, LINE 1A: THE THIRD PARTY ADMINISTRATOR FOR THE PLAN A HEALTH CARE PLAN TRUST FILES JOINT FORMS 1099 FOR ALL PLANS UNDER THEIR ADMINISTRATION. FORM 990, PART VI, SECTION A, LINE 8A THE NATURE OF THE ENTITY DOES NOT REQUIRE REGULARLY SCHEDULED AND STRUCTURED MEETINGS WITH THE TRUSTEE. THE PURPOSE OF THE ENTITY IS TO ACT AS A CONDUIT FOR MEDICAL BENEFIT PREMIUMS TO BE USED FOR PAYMENT OF MEDICAL CLAIMS OF THE PARTICIPANTS. THE TRUSTEE OVERSEES THE RECEIPT OF PREMIUMS AND THE PAYMENT OF BENEFITS AS REQUIRED, AND ALSO MAKES CERTAIN THAT THE THIRD PARTY ADMINISTRATOR FULFILLS ITS RESPONSIBILITIES. FORM 990, PART VI, SECTION A, LINE 8B THE NATURE OF THE ENTITY DOES NOT REQUIRE REGULARLY SCHEDULED AND STRUCTURED MEETINGS WITH THE TRUSTEE. THE PURPOSE OF THE ENTITY IS TO ACT AS A CONDUIT FOR MEDICAL BENEFIT PREMIUMS TO BE USED FOR PAYMENT OF MEDICAL CLAIMS OF THE PARTICIPANTS. THE TRUSTEE OVERSEES THE RECEIPT OF PREMIUMS AND THE PAYMENT OF BENEFITS AS REQUIRED, AND ALSO MAKES CERTAIN THAT THE THIRD PARTY ADMINISTRATOR FULFILLS ITS RESPONSIBILITIES. FORM 990, PART VI, SECTION B, LINE 11B THE TRUSTEE RECEIVES A PAPER COPY OF FORM 990 FOR THEIR REVIEW AND COMMENT PRIOR TO ITS FILING. FORM 990, PART VI, SECTION C, LINE 18 A PAPER COPY OF FORM 990 IS PROVIDED UPON REQUEST. THE ORGANIZATION'S FORM 990 IS ALSO AVAILABLE VIA THE GUIDESTAR.ORG WEBSITE. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC EXCEPT THROUGH PUBLIC FILING REQUIREMENTS. FORM 990, PART VI, SECTION B, LINE 12A: A CONFLICT OF INTEREST POLICY IS NOT REQUIRED FOR THIS ENTITY. THE TRUSTEE RECEIVES NO PAYMENTS OR COMPENSATION FROM THE PLAN A HEALTH CARE PLAN TRUST. THE TRUSTEE IS EMPLOYED BY RFMS, INC. AND RFMS, INC., PROVIDES ADMINISTRATIVE SERVICES TO THE PLAN FREE OF CHARGE. FORM 990, PART VII, SECTION A, LINE 1A, COLUMN B: THE TRUSTEE DEVOTES A PORTION OF THE AVERAGE HOURS PER WEEK TO THE RELATED ORGANIZATIONS LISTED ON SCHEDULE R. HOWEVER, THE ACTUAL HOURS ATTRIBUTABLE TO THESE RELATED ORGANIZATIONS IS NOT SPECIFICALLY TRACKED. THE HOURS REPORTED IN COLUMN B ARE A REASONABLE ESTIMATE, AND THE TRUSTEE NORMALLY DEVOTES LESS THAN ONE HOUR PER WEEK TO THE PLAN A HEALTH CARE PLAN TRUST. FORM 990, PART VIII, LINE 3 AND PART V, LINE 3A: THE ORGANIZATION IS NOT SUBJECT TO UNRELATED BUSINESS INCOME TAX ON INVESTMENT INCOME UNDER SECTION 512(A)(3)(E)(III). SUBSTANTIALLY ALL OF THE CONTRIBUTIONS TO THE PLAN A HEALTH CARE PLAN TRUST ARE MADE BY EMPLOYERS WHO WERE EXEMPT FROM TAX THROUGHOUT THE 5-TAXABLE-YEAR PERIOD ENDING WITH THE TAXABLE YEAR IN WHICH THE CONTRIBUTIONS ARE MADE. FORM 990, PART XI, LINE 9: TRANSFER OF ASSETS FROM RFMS MEDICAL BENEFIT PLAN TRUST (EIN: 36-7042729) 9,604. FORM 990, PART XII, LINE 2C: THE PROCESS FOR OVERSIGHT OF THE AUDIT AND SELECTION OF INDEPENDENT ACCOUNTANT IS THAT THE TWO TRUSTEES MAKE ARRANGEMENTS FOR THE AUDIT, HOWEVER THE ORGANIZATION DOES NOT HAVE A SEPERATE AUDIT COMMITTEE. COMMUNITY LIVING OPTIONS INC RESIDENTIAL ALTERNATIVES OF ILLINOIS INC UNLIMITED DEVELOPMENT INC FRANCES HOUSE INC ACHIEVEMENT UNLIMITED INC PINNACLE OPPORTUNITIES INC PIONEER CONCEPTS INC DESERT HEALTH CARE FACILITIES INC FLORIDA LIVING OPTIONS INC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 SCHEDULE R, PART IV: