BLUE LAKE RANCHERIA EMPLOYEE BENEFITS TR: Form 990, tax year 2022
View the entire original 990 at ProPublica ↗
- Organization
- BLUE LAKE RANCHERIA EMPLOYEE BENEFITS TR (EIN 80-0928592)
- Tax period
- 2022-01-01 to 2022-12-31
- Filed
- 2023-04-24
- IRS object ID
- 202301149349301045
- Schema version
- 2022v5.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2023-04-24T16:12:33-04:00 | ReturnTs |
| Tax Period End | 2022-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 680402428 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | AYCOCK AND EDGMON CPA | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 637 | AddressLine1Txt |
| City | FERNDALE | CityNm |
| State Abbreviation | CA | StateAbbreviationCd |
| ZIP | 955360637 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2022-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 800928592 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | BLUE LAKE RANCHERIA EMPLOYEE BENEFI | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | BLUE | BusinessNameControlTxt |
| Phone | 7074991186 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 140 WEBSTER STREET | AddressLine1Txt |
| City | RIO DELL | CityNm |
| State Abbreviation | CA | StateAbbreviationCd |
| ZIP | 95562 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | PHILIP AYCOCK | PersonNm |
| Person Title | TREASURER | PersonTitleTxt |
| Phone | 7077869798 | PhoneNum |
| Signature | 2023-04-20 | SignatureDt |
| Discuss With Paid Preparer | Yes (true) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | PHILIP | PersonFirstNm |
| Person Last | AYCOCK | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | XXX-XX-XXXX | SSN |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IRS Responsible Prty Info Curr | false | IRSResponsiblePrtyInfoCurrInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | STACEY R EDGMON | PreparerPersonNm |
| PTIN | P00128058 | PTIN |
| Phone | 7077869798 | PhoneNum |
| Preparation | 2023-04-21 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2022 | TaxYr |
| Build TS | 2023-04-26 12:10:37Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | ARLA RAMSEY | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 428 CHARTIN ROAD | AddressLine1Txt |
| City | BLUE LAKE | CityNm |
| State Abbreviation | CA | StateAbbreviationCd |
| ZIP | 95525 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $1,936,889 | GrossReceiptsAmt |
| Group Return For Affiliates | false | GroupReturnForAffiliatesInd |
| Organization501c | Yes (X) | Organization501cInd |
| Type Of Organization Trust | Yes (X) | TypeOfOrganizationTrustInd |
| Formation | 2013 | FormationYr |
| Legal Domicile State | CA | LegalDomicileStateCd |
| Activity Or Mission | ESTABLISH A TRUST TO FUND WELFARE BENEFIT PLANS FOR ELIGIBLE EMPLOYEES OF THE BLUE LAKE RANCHERIA AND ITS AFFILIATES, INCLUDING THE BLUE LAKE RANCHERIA SELF-INSURANCE HEALTH PLAN. | ActivityOrMissionDesc |
| Voting Members Governing Body | 5 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 5 | VotingMembersIndependentCnt |
| Total Employee | 0 | TotalEmployeeCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| CY Contributions Grants | $0 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $1,649,763 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $1,888,973 | CYProgramServiceRevenueAmt |
| PY Investment Income | $177,667 | PYInvestmentIncomeAmt |
| CY Investment Income | $47,916 | CYInvestmentIncomeAmt |
| CY Other Revenue | $0 | CYOtherRevenueAmt |
| PY Total Revenue | $1,827,430 | PYTotalRevenueAmt |
| CY Total Revenue | $1,936,889 | CYTotalRevenueAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $1,203,917 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $1,428,000 | CYBenefitsPaidToMembersAmt |
| CY Salaries Comp Emp Bnft Paid | $0 | CYSalariesCompEmpBnftPaidAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $427,831 | PYOtherExpensesAmt |
| CY Other Expenses | $198,107 | CYOtherExpensesAmt |
| PY Total Expenses | $1,631,748 | PYTotalExpensesAmt |
| CY Total Expenses | $1,626,107 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $195,682 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $310,782 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $1,347,767 | TotalAssetsBOYAmt |
| Total Assets EOY | $1,440,287 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $308 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $0 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $1,347,459 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $1,440,287 | NetAssetsOrFundBalancesEOYAmt |
| Mission | ESTABLISH A TRUST TO FUND WELFARE BENEFIT PLANS FOR ELIGIBLE EMPLOYEES OF THE BLUE LAKE RANCHERIA AND ITS AFFILIATES, INCLUDING THE BLUE LAKE RANCHERIA SELF-INSURANCE HEALTH PLAN. | MissionDesc |
| Significant New Program Srvc | false | SignificantNewProgramSrvcInd |
| Significant Change | false | SignificantChangeInd |
| Desc | PROVIDE HEALTH BENEFITS TO PARTICIPANTS THROUGH THE BLUE LAKE RANCHERIA HEALTH PLAN | Desc |
| Described In Section501c3 | false | DescribedInSection501c3Ind |
| Schedule B Required | false | ScheduleBRequiredInd |
| Political Campaign Acty | false | PoliticalCampaignActyInd |
| Subject To Proxy Tax | false | SubjectToProxyTaxInd |
| Donor Advised Fund | false | DonorAdvisedFundInd |
| Conservation Easements | false | ConservationEasementsInd |
| Collections Of Art | false | CollectionsOfArtInd |
| Credit Counseling | false | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | false | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | false | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | false | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | false | ReportProgramRelatedInvstInd |
| Report Other Assets | false | ReportOtherAssetsInd |
| Report Other Liabilities | false | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | false | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | false | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | false | ConsolidatedAuditFinclStmtInd |
| School Operating | false | SchoolOperatingInd |
| Foreign Office | false | ForeignOfficeInd |
| Foreign Activities | false | ForeignActivitiesInd |
| More Than5000 K To Org | false | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | false | MoreThan5000KToIndividualsInd |
| Professional Fundraising | false | ProfessionalFundraisingInd |
| Fundraising Activities | false | FundraisingActivitiesInd |
| Gaming Activities | false | GamingActivitiesInd |
| Operate Hospital | false | OperateHospitalInd |
| Grants To Organizations | false | GrantsToOrganizationsInd |
| Grants To Individuals | false | GrantsToIndividualsInd |
| Schedule J Required | false | ScheduleJRequiredInd |
| Tax Exempt Bonds | false | TaxExemptBondsInd |
| Loan Outstanding | false | LoanOutstandingInd |
| Grant To Related Person | false | GrantToRelatedPersonInd |
| Business Rln With Org Mem | false | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | false | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | false | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | false | DeductibleNonCashContriInd |
| Deductible Art Contribution | false | DeductibleArtContributionInd |
| Terminate Operations | false | TerminateOperationsInd |
| Partial Liquidation | false | PartialLiquidationInd |
| Disregarded Entity | false | DisregardedEntityInd |
| Related Entity | false | RelatedEntityInd |
| Related Organization Ctrl Ent | false | RelatedOrganizationCtrlEntInd |
| Activities Conducted Prtshp | false | ActivitiesConductedPrtshpInd |
| Schedule O Required | false | ScheduleORequiredInd |
| IRP Document | 0 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 0 | EmployeeCnt |
| Unrelated Bus Incm Over Limit | false | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | false | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | false | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | false | TaxablePartyNotificationInd |
| Nondeductible Contributions | false | NondeductibleContributionsInd |
| Indoor Tanning Services | false | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | false | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | false | SubjectToExcsTaxNetInvstIncInd |
| Governing Body Voting Members | 5 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 5 | IndependentVotingMemberCnt |
| Family Or Business Rln | false | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | false | DelegationOfMgmtDutiesInd |
| Change To Org Documents | false | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | false | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | false | MembersOrStockholdersInd |
| Election Of Board Members | false | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | false | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (true) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (true) | MinutesOfCommitteesInd |
| Officer Mailing Address | false | OfficerMailingAddressInd |
| Local Chapters | false | LocalChaptersInd |
| Form990 Provided To Gvrn Body | false | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | false | ConflictOfInterestPolicyInd |
| Whistleblower Policy | false | WhistleblowerPolicyInd |
| Document Retention Policy | false | DocumentRetentionPolicyInd |
| Compensation Process CEO | false | CompensationProcessCEOInd |
| Compensation Process Other | false | CompensationProcessOtherInd |
| Investment In Joint Venture | false | InvestmentInJointVentureInd |
Books In Care Of Detail BooksInCareOfDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | PHILIP AYCOCK | PersonNm |
| Phone | 7074991186 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 140 WEBSTER STREET | AddressLine1Txt |
| City | RIO DELL | CityNm |
| State Abbreviation | CA | StateAbbreviationCd |
| ZIP | 95536 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| No Listed Persons Compensated | Yes (X) | NoListedPersonsCompensatedInd |
Form990 Part VII Section A Form990PartVIISectionAGrp (5 entries)
| TitleTitleTxt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd |
|---|---|---|---|---|---|
| JASON RAMOS | |||||
| MEMBER AT LA | Yes (X) | $0 | $0 | $0 | |
| PHILIP AYCOCK | |||||
| TREASURER | $0 | $0 | $0 | Yes (X) | |
| CLAUDIA BRUNDIN | |||||
| CHAIRPERSON | $0 | $0 | $0 | Yes (X) | |
| ARLA RAMSEY | |||||
| VICE CHAIRPE | $0 | $0 | $0 | Yes (X) | |
| ARTHUR RAMSEY | |||||
| SECRETARY | $0 | $0 | $0 | Yes (X) | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Former Ofcr Employees Listed | false | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | false | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | false | CompensationFromOtherSrcsInd |
Program Service Revenue ProgramServiceRevenueGrp (2 entries)
| DescDesc | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|
| PREMIUM INCOME | $1,866,695 | $1,866,695 |
| REFUNDS | $22,278 | $22,278 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $1,888,973 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $47,858 | TotalRevenueColumnAmt |
| Exclusion | $47,858 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $58 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $58 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $58 | TotalRevenueColumnAmt |
| Exclusion | $58 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,936,889 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $1,888,973 | RelatedOrExemptFuncIncomeAmt |
| Exclusion | $47,916 | ExclusionAmt |
Benefits To Members BenefitsToMembersGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,428,000 | TotalAmt |
| Program Services | $1,428,000 | ProgramServicesAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $198,107 | TotalAmt |
| Program Services | $92,480 | ProgramServicesAmt |
| Management And General | $105,627 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,626,107 | TotalAmt |
| Program Services | $1,520,480 | ProgramServicesAmt |
| Management And General | $105,627 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | -$1 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $196,549 | BOYAmt |
| EOY | $473,288 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,151,218 | BOYAmt |
| EOY | $967,000 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,347,767 | BOYAmt |
| EOY | $1,440,287 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $308 | BOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $308 | BOYAmt |
| EOY | $0 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Org Does Not Follow FASB117 | Yes (X) | OrgDoesNotFollowFASB117Ind |
Rtn Earn Endowment Incm Oth Fnds RtnEarnEndowmentIncmOthFndsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,347,459 | BOYAmt |
| EOY | $1,440,287 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,347,459 | BOYAmt |
| EOY | $1,440,287 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,347,767 | BOYAmt |
| EOY | $1,440,287 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $310,782 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | -$217,954 | NetUnrlzdGainsLossesInvstAmt |
| Method Of Accounting Cash | Yes (X) | MethodOfAccountingCashInd |
| Accountant Compile Or Review | false | AccountantCompileOrReviewInd |
| FS Audited | false | FSAuditedInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PAGE 6, PART VI, LINE 11B | NO REVIEW WAS OR WILL BE CONDUCTED. |
| FORM 990, PAGE 6, PART VI, LINE 19 | NO DOCUMENTS AVAILABLE TO THE PUBLIC |
Comments