2023-03-22T11:02:17-05:00 2022-05-31 131578842 BUCHBINDER TUNICK & COMPANY LLP ONE PENNSYLVANIA PLAZA SUITE 3200 NEW YORK NY 10119 990 2021-06-01 111637886 LOCAL 804 WELFARE TRUST FUND LOCA 7187865410 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 VINCENT PERRONE TRUSTEE 7187865410 2023-03-18 1 VINCENT PERRONE 999009999 GREG AUTERI P01366109 2126955003 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z VINCENT PERRONE 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 147614756 0 X HTTP://WWW.LOCAL804FUND.COM X 1950 NY TO PROVIDE HEALTH CARE BENEFITS 8 4 23 0 0 0 0 0 119663197 129167513 6471449 2932472 23456 147358 126158102 132247343 0 0 96970497 115650464 2535632 2501875 0 0 0 1917760 2025238 101423889 120177577 24734213 12069766 147164982 153577922 957923 5831716 146207059 147746206 X THE LOCAL 804 WELFARE TRUST FUND WAS CREATED IN 1950, UNDER AN AGREEMENT AND DECLARATION OF TRUST, AS AMENDED, BETWEEN DELIVERY AND WAREHOUSE EMPLOYEES UNION, LOCAL 804 IBT (THE UNION") AND VARIOUS EMPLOYERS. THE UNION AND THE EMPLOYERS HAVE ENTERED INTO COLLECTIVE BARGAINING AGREEMENTS REQUIRING PAYMENTS BY THE EMPLOYERS FOR THE PURPOSE OF ESTABLISHING A WELFARE PROGRAM FOR THE EMPLOYERS TO PROVIDE WELFARE BENEFITS FOR THEIR EMPLOYEES AND THE EMPLOYEES OF THE UNION, AND THE EMPLOYEES OF THE LOCAL 804 WELFARE TRUST FUND. 0 0 PROVIDED HEALTH CARE BENEFITS FOR ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS. ESTIMATED NUMBER OF PARTICIPANTS BENEFITED DURING THE PAST YEAR WAS 5914. 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1 962 0 1 23 1 0 0 0 0 0 0 0 0 X 8 4 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 1 1 0 X MARC PANTELEONE FUND MANAGER 7187865410 34-21 REVIEW AVENUE LONG ISLAND CITY NY 11101 CHRIS LANGAN EMPLOYER TRUSTEE 1.00 X 0 0 0 MARK MCELREATH EMPLOYER TRUSTEE 1.00 X 0 0 0 MATTHEW LOUGHLIN EMPLOYER TRUSTEE 1.00 X 0 0 0 MICHAEL CLAYTON EMPLOYER TRUSTEE 1.00 X 0 0 0 VINCENT PERRONE UNION TRUSTEE 1.00 40.00 X 0 135139 55823 ANTONINO ROSCIGLIONE UNION TRUSTEE 1.00 40.00 X 0 135039 55823 CHRISTOPHER WILLIAMSON UNION TRUSTEE 1.00 40.00 X 0 135139 55823 ANTHONY CERULLI UNION TRUSTEE 1.00 40.00 X 0 135039 55823 MARC PANTELEONE FUND MANAGER 27.00 8.00 X 207692 0 58084 JAMES PANTELEONE IT AND BENEFIT CLAIMS ASSI 54.00 1.00 X 134966 0 31756 MAGGIE WU ACCOUNTANT 34.00 19.00 X 183815 0 31987 CELIA LIAW BENEFIT CLAIMS ASSISTANT 45.00 1.00 X 110864 0 31780 CHRISTINE NICOLETTI OFFICE MANAGER 35.00 1.00 X 102965 0 58084 740302 540356 434983 5 0 1 0 EMPIRE HEALTHCHOICE ASSURANCE INC 165 BROADWAY NEW YORK NY 10006 BENEFIT ADMINISTRATIVE SERVICE 2144845 NEW YORK MEDICAL MANAGEMENT 2025 LINCOLN HIGHWAY ROUTE 21 EDISON NJ 08817 BENEFIT CONSULTING SERVICES 429353 THE SEGAL COMPANY (EASTERN STATES) INC 333 WEST 34TH STREET NEW YORK NY 10001 ACTUARIAL AND CONSULTING SERVICES 426302 HEALTH PLAN SYSTEM 2025 LINCOLN HIGHWAY ROUTE 21 EDISON NJ 08817 BENEFIT INFORMATION TECHNOLOGY 368428 PROSKAUER ROSE LLP ELEVEN TIMES SQUARE NEW YORK NY 10036 LEGAL SERVICES 356131 5 CONTRIBUTIONS - EMPLOYERS 900099 126186164 126186164 CONTRIBUTIONS - RETIRED PARTICIPA 900099 2846051 2846051 CONTRIBUTIONS - COBRA PARTICIPANT 900099 135298 135298 129167513 2974241 2974241 15325644 15367413 -41769 -41769 -41769 MISCELLANEOUS INCOME 900099 147358 147358 147358 132247343 129314871 0 2932472 115650464 268684 1548416 134175 414017 136583 521088 49000 201683 421521 219599 566001 101906 37790 73825 57328 ADM.EXPENSES REIMBURSED -225027 524 120177577 2783508 2525890 14671527 20377728 15026658 12761328 56481 72944 3612622 3411078 267600 201544 85715652 86471910 28643556 31166578 147164982 153577922 111262 435181 262251 269998 584410 5126537 957923 5831716 X 0 0 0 0 146207059 147746206 146207059 147746206 147164982 153577922 12069766 -10530619 0 X 0 1 X 0 0 339467 336286 3181 869632 800644 68988 2403523 2274148 129375 201544 COMMON COLLECTIVE TRUST 12223381 F LIMITED PARTNERSHIP 14505083 F ETF 4438114 F 31166578 EST'D FUTURE RETIREMENT BENEFIT 103644 DUE TO LOCAL 804 ANNUITY FUND 32705 DUE TO BROKER 4972875 DUE TO LOCAL 804 PENSION FUND 17313 5126537 X 121515041 -10530619 -10530619 132045660 201683 201683 132247343 119975894 0 119975894 201683 201683 120177577 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 THE PLAN HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE. THE PLAN ADMINISTRATOR HAS ANALYZED THE TAX POSITIONS TAKEN BY THE PLAN, AND HAS CONCLUDED THAT AS OF MAY 31, 2022, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY (OR ASSET) OR DISCLOSURE IN THE FINANCIAL STATEMENTS. EMPLOYEE BENEFIT PLANS ARE SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS FOR THE PLAN. THE PLAN ADMINISTRATOR BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO MAY 31, 2019. 0 0 0 MARC PANTELEONE FUND MANAGER 207692 0 0 0 0 0 33184 0 24900 0 265776 0 0 0 MAGGIE WU ACCOUNTANT 183815 0 0 0 0 0 6325 0 25662 0 215802 0 0 0 VINCENT PERRONE UNION TRUSTEE 0 135139 0 0 0 0 0 30923 0 24900 0 190962 0 0 CHRISTOPHER WILLIAMSON UNION TRUSTEE 0 135139 0 0 0 0 0 30923 0 24900 0 190962 0 0 ANTONINO ROSCIGLIONE UNION TRUSTEE 0 135039 0 0 0 0 0 30923 0 24900 0 190862 0 0 ANTHONY CERULLI UNION TRUSTEE 0 135039 0 0 0 0 0 30923 0 24900 0 190862 0 0 JAMES PANTELEONE IT AND BENEFIT CLAIMS ASSI 134966 0 0 0 0 0 6325 0 25431 0 166722 0 0 0 CHRISTINE NICOLETTI OFFICE MANAGER 102965 0 0 0 0 0 33184 0 24900 0 161049 0 0 0 FORM 990, PART VI, SECTION A, LINE 8B THE FUND DOES NOT HAVE ANY COMMITTEE WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE FUND'S BOARD OF TRUSTEES REVIEWS THE FORM 990 PRIOR TO ITS FILING. FORM 990, PART VI, SECTION B, LINE 15 THE FUND'S BOARD OF TRUSTEES REVIEWS AND AUTHORIZES COMPENSATION FOR ALL EMPLOYEES, INCLUDING FOR THE TOP MANAGEMENT OFFICIAL. THE REVIEW PROCESS IS CONDUCTED AT THE BOARD MEETING AND DOCUMENTED ACCORDINGLY. FORM 990, PART VI, SECTION C, LINE 19 THE FUND MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON RECEIPT OF A PARTICIPANT'S WRITTEN REQUEST. LOCAL 804 ANNUITY FUND 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 112506358 SHARED ADMINISTRATIVE COST NY 1.401-1(B)(3) 0 LOCAL 804 IBT 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 111603598 CONTRIBUTING EMPLOYER & RENTAL EXPENSE NY 501(C)(5) 0 LOCAL 804 FEDERAL CREDIT UNION 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 112491081 CONTRIBUTING EMPLOYER NY 501(C)(1) 0 LOCAL 804 PENSION FUND 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 116077200 SHARED ADMINISTRATIVE COST NY 1.401-1(B)(3) 0 UNITED PARCEL SERVICE CONTRIBUTING EMPLOYER 0 TRUMP VILLAGE INC CONTRIBUTING EMPLOYER 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 1 0 0 LOCAL 804 ANNUITY FUND O 99680 SHARED ADM. COST AGREEMENT LOCAL 804 ANNUITY FUND N 75805 SHARED ADM. COST AGREEMENT LOCAL 804 IBT K 61560 OFFICE RENTAL EXPENSE LOCAL 804 PENSION FUND O 31218 SHARED ADM. COST AGREEMENT LOCAL 804 PENSION FUND N 18324 SHARED ADM. COST AGREEMENT LOCAL 804 PENSION FUND Q 44391 SHARED ADM. COST AGREEMENT LOCAL 804 ANNUITY FUND Q 131692 SHARED ADM. COST AGREEMENT BOYD WATTERSON STATE GOVERNMENT FUND LP ONE NORTH WACKER DRIVE SUITE 4025 CHICAGO IL 60606 320538379 INVESTMENT IL 492527 0 13407582 0 0 0 0.00950