2022-04-21T11:50:50-05:00 2021-06-30 222027092 WITHUMSMITHBROWN PC 5000 EXECUTIVE PARKWAY SUITE 400 SAN RAMON CA 945834210 990 2020-07-01 942541328 SHEET METAL WORKERS LOCAL 104 HEALTH CARE PLAN SHEE 9252089999 3240B CONSTITUTION DRIVE LIVERMORE CA 94551 RICK WERNER TRUSTEE 9252089999 2022-04-21 1 RICK WERNER 999009999 JESSICA R ROSTER P01317380 9252779100 3 AAL1 IAL1 2020 2022-09-23 18:48:47Z X RICK WERNER 3240B CONSTITUTION DRIVE LIVERMORE CA 94551 122415535 0 X N/A X 1979 CA TO PROVIDE HEALTH BENEFITS AND SUPPLEMENTAL UNEMPLOYMENT BENEFITS 14 0 0 0 0 0 0 0 120782774 119274871 15666216 3140664 0 0 136448990 122415535 0 0 94914593 114089884 57202 55834 0 0 0 5198094 4989107 100169889 119134825 36279101 3280710 221679948 245411370 36819222 42360683 184860726 203050687 TO PROVIDE HEALTH BENEFITS AND SUPPLEMENTAL UNEMPLOYMENT BENEFITS. 0 0 PROVIDED HEALTH AND WELFARE BENEFITS AND SUPPLEMENTAL UNEMPLOYMENT BENEFITS TO PARTICIPANTS AND THEIR ELIGIBLE DEPENDENTS. 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 7 0 1 0 1 0 0 0 0 0 0 0 0 X 14 0 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X BENESYS INC 9252089994 3240B CONSTITUTION DRIVE LIVERMORE CA 94551 X RICK WERNER CHAIRMAN 4.00 X 0 0 0 RICHARD KOENIG TRUSTEE 2.00 X 0 0 0 BRIAN WERNER TRUSTEE 2.00 X 0 0 0 BRIAN MASTERS TRUSTEE 2.00 X 0 0 0 DOMINIC TORREANO TRUSTEE 2.00 X 0 0 0 KEITH DIAS TRUSTEE 2.00 X 0 0 0 JOSEPH MARACCINI TRUSTEE 2.00 X 0 0 0 ERIC HAYNES TRUSTEE 2.00 X 0 0 0 SEAN O'DONOGHUE TRUSTEE 2.00 X 0 0 0 BOB BRAMLETT TRUSTEE 2.00 X 0 0 0 CHRIS ENFANTINO TRUSTEE 2.00 X 0 0 0 PAUL STECKEL TRUSTEE 2.00 X 0 0 0 KATHY DE JONG TRUSTEE 2.00 X 0 0 0 DUANE DAVIES TRUSTEE 2.00 X 0 0 0 RANDY ATTAWAY TRUSTEE - PAST 2.00 X 0 0 0 SEE SCHEDULE O FOR COMPENSATION PAI PAID BY RELATED ORGANIZATIONS 0.00 X 0 1 0 0 1 0 0 0 0 0 BENESYS INC 2610 CROW CANYON ROAD SUITE 200 SAN RAMON CA 94583 ADMINISTRATION 2625683 BLUE SHIELD OF CALIFORNIA 50 BEALE STREET SAN FRANCISCO CA 941051808 CLAIMS PROCESSING 1483907 DELTA DENTAL OF CALIFORNIA PO BOX 997330 SACRAMENTO CA 958997330 CLAIMS PROCESSING 683668 PART D ADVISORS INC 17199 N LAUREL PARK DR STE 400 LIVONIA MI 48152 CONSULTING 134639 NORTHWEST PLAN SERVICES INC 160 W SANTA CLARA STREET SUITE 15 SAN JOSE CA 95113 CONSULTING 116000 6 EMPLOYER CONTRIBUTIONS 900099 102674122 102674122 EMPLOYEE CONTRIBUTIONS 900099 12801728 12801728 PRESCRIPTION REBATES 900099 2094054 2094054 MEDICARE - D REBATES 900099 1612614 1612614 MISC. INCOME 900099 92353 92353 119274871 3140664 3140664 122415535 119274871 0 3140664 114089884 55834 2397004 102452 43777 83830 2082323 171159 1265 52797 SETTLEMENT 35000 PCORI TAX 19500 119134825 -219166 -314204 62040340 49290528 20598109 22135473 53579 50000 139207086 174249573 221679948 245411370 821295 948361 1027927 1009322 34970000 40403000 36819222 42360683 X 0 0 0 0 184860726 203050687 184860726 203050687 221679948 245411370 3280710 14909251 0 X X 0 1 X 1 0 0 ACCUMULATED ELIGIBILITY CREDITS 29893000 CLAIMS PAYABLE & INCURRED BUT NOT REPORTED CLAIMS 10510000 40403000 X 137240956 14909251 14909251 122331705 83830 83830 122415535 113617995 0 113617995 83830 5433000 5516830 119134825 PART X, LINE 2: THE PLAN'S ADMINISTRATOR HAS ANALYZED THE TAX POSITIONS TAKEN BY THE PLAN AND HAS CONCLUDED THAT, AS OF JUNE 30, 2021, THERE ARE NO UNCERTAIN POSITIONS TAKEN, OR EXPECTED TO BE TAKEN, THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY THE TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE PLAN'S ADMINISTRATOR BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR THE FISCAL YEARS PRIOR TO 2018. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN BENEFIT OBLIGATIONS FORM 990, PART VI, SECTION A, LINE 3 THE PLAN HAS CONTRACTED WITH BENESYS, INC. TO PROVIDE ADMINISTRATIVE SERVICES FOR THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF THE FORM 990 WAS PROVIDED TO THE BOARD OF TRUSTEES FOR REVIEW BEFORE IT WAS FILED. FORM 990, PART VI, SECTION B, LINE 12C TRUSTEES ARE REQUIRED TO DISCLOSE IN WRITING ANY RELATIONSHIPS OR INTEREST THAT COULD GIVE RISE TO A CONFLICT. IF THERE IS A CONFLICT OF INTEREST, THE CONFLICTING INTEREST IS FULLY DISCLOSED AND DOCUMENTED IN WRITING; THE TRUSTEE OR FIDUCIARY WITH THE CONFLICT OF INTEREST IS EXCLUDED FROM THE DISCUSSION AND APPROVAL OF SUCH TRANSACTION. FORM 990, PART VI, SECTION C, LINE 19 UPON REQUEST, THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT-OF-INTEREST POLICY AND FINANCIAL INFORMATION AVAILABLE. FORM 990, PART VII, SECTION A, LINE 1A: TRUSTEES ARE NOT COMPENSATED BY THE TRUST. COMPENSATION PAID TO TRUSTEES EMPLOYED BY OTHER RELATED ORGANIZATIONS IS REPORTED ON THE FORM 990 FILED WITH THE INTERNAL REVENUE SERVICE BY THE RELATED TAX EXEMPT ORGANIZATION. IF YOU WOULD LIKE ADDITIONAL INFORMATION, PLEASE CONTACT THE THIRD-PARTY ADMINISTRATOR, BENESYS, INC. FORM 990, PART XII LINE 2C: THE ORGANIZATION HAS A BOARD OF TRUSTEES THAT ASSUMES RESPONSIBLITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED. LOCAL 104 SUPPLEMENTAL PENSION PLAN 3240B CONSTITUTION DRIVE LIVERMORE CA 94551 946560138 THE PLAN PROVIDES SUPPLEMENTAL PENSION BENEFITS CA 501A N/A N/A 0 SHEET METAL WORKERS PENSION TRUST OF NORTHERN CALIFORNIA 3240B CONSTITUTION DRIVE LIVERMORE CA 94551 516115939 THE PLAN PROVIDES PENSION BENEFITS TO RETIREES CA 501A N/A N/A 0 SHEET METAL WORKERS INTERNATIONAL ASSN LOCAL UNION NO 104 3232 CONSTITUTION DRIVE LIVERMORE CA 94551 940859420 UNION CA 501C(5) N/A N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 SCHEDULE R, IDENTIFICATION OF RELATED ORGANIZATIONS: THE FILING ORGANIZATION IS A TAFT-HARTLEY MULTIEMPLOYER TRUST THAT PROVIDES HEALTH AND WELFARE BENEFITS TO ELIGIBLE EMPLOYEES AND THEIR DEPENDENTS. AS OF JUNE 30, 2021, THERE ARE APPROXIMATELY 216 EMPLOYERS THAT CONTRIBUTE TO THE TRUST. THE ADMINISTRATIVE OFFICE MAINTAINS A DATABASE OF THESE CONTRIBUTING EMPLOYERS, INCLUDING NAMES, ADDRESSES AND OTHER CONTACT INFORMATION. THE FEDERAL TAX CLASSIFICATION (DISREGARDED ENTITY, TAX-EXEMPT ORGANIZATION, PARTNERSHIP, TAXABLE CORPORATION OR TRUST) FOR EACH CONTRIBUTING EMPLOYER IS NOT ON FILE WITH THE ADMINISTRATIVE OFFICE AND IT COULD NOT BE REASONABLY OBTAINED. AS A RESULT, THE NAMES OF THE CONTRIBUTING EMPLOYERS ARE LISTED ON PART VII BELOW AND NOT ON PARTS II THROUGH IV BY FEDERAL TAX CLASSIFICATION. A & B MECHANICAL, INC. A G C, INC A I M SHEET METAL A. ZAHNER CO. AAERO HEATING & S/M CO ABCO MECHANICAL CONTR ABM BUILDING SOLUTIONS, LLC ABOVO SOLUTIONS, LLC ACCEL AIR SYSTEMS INC. ACCO ENGINEERED SYS ACI MECHANICAL INC. ADVANCED AIRE SYSTEMS ADVANCED SOLUTIONS,INC ADVNC AIR TECHNOLOGIES AGC INC. AIR CONDITIONING SYSTEM AIR EXCHANGE AIR SYSTEMS SERVICE & CONST. AIR SYSTEMS, INC. AIRCAL HTG. & S/M AIRCO MECHANICAL INC AIRE SHEET METAL AIRTEC SERVICE AKIMA, LLC ALL BAY MECHANICAL, INC. 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CONGI INC. DBA CARTER AIR CONTROL AIR ENTERPRISE, LLC CRITCHFIELD MECHANICAL CROWN CORR, INC. CROWN SHEET METAL & CULINARY STAINLESS FABRICATORS DDK MECHANICAL, INC. DEBELLA MECHANICAL,INC DEGREE HVAC, INC. DEHARO MECHANICAL INC. DELCON HEATING & A/C, INC. DELLA MORA HTG,S/M, & A/C, INC DEPENDABLE SHEET METAL DESERT MECHANICAL, INC. DOWDLE & SONS MECHANICAL, INC DOWNING HEATING & AIR COND. DURR EAST BAY RESTAURANT INSTALL. ECHO MECHANICAL SYSTEMS ENERGY MECHANIX INC. ENVIRONMENTAL SYSTEMS INC. EXTREME AIR INC F S I FAIRVIEW HEATING & A/C FERTADO HEATING & AIR, INC. FOOTHILL AIR COND FRANK M BOOTH GLOBAL SPECIALTIES DIRECT, INC H-SQUARE MECHANICAL, INC. HARDIN & SONS, INC. HARRIS BAY AREA, LLC HARRIS MOUNTAIN WEST, LLC HEATHORN & ASSOCIATES DBA HVAC CAD SERVICE HYDRA VENTURES, INC. I E S INDOO ENVIRO SVS ICOM MECHANICAL INDEPENDENT AIR BALANCE, INC. INFINITY MECHANICAL, INC. INNOVATIVE MECH INC INTECH MECHANICAL CO., INC. IZMIRIAN ROOFING & S/M JACOBSEN ALVES GOODEILL INC. JAMES LONG CONSTRUCTION JEFFCO CUSTOM METALS, INC. JENSEN MECHANICAL, INC. JEROME & HORNER SHEET METAL JMS MECHANICAL K & M INSTALLATION KAMRAN METAL WORKS, INC. KEL AIRE HTG KINETIC MECHANICAL SERVICE INC KINETIC SYSTEMS, INC KT MECHANICAL INC. L J KRUSE COMPANY LARGE'S METAL FAB LASLEY MECHANICAL LAWSON MECHANICAL LEFCO INC M T B INCORPORATED M.E.S.A. 3, INC MARELICH MECHANICAL CO MARTINEZ SHEET METAL MATRIX HG, INC. MAUCK SHEET METAL WORKS MECHANICAL SERVICES LLC MELROSE METAL PRODUCTS MESA ENERGY SYSTEMS INC. MG MCGRATH, INC. MILESTONE CONTRACTORS INC. DBA MINA METALS MIRADOR CONSTRUCTION MONARCH MECHANICAL MONSTER MECHANICAL, INC. MONTEREY MECHANICAL CO MSR MECHANICAL LLC MURRAY PLUMBING & HTG CORP. NATIONAL AIR BALANCE NATIONAL SHOP FAB INC. NEW ENGLAND S/M AND MECH. CO. NORTH BAY COMMERCIAL SVCS INC NORTHERN SERVICES, INC. O C MCDONALD CO., INC. OCEAN PARK MECHANICAL, INC. OMNI SHEET METAL, INC. ORSON MECHANICAL CO., INC. OTAVILLA MECHANICAL CONTR. PACIFIC COAST BALANCING PACIFIC COAST TRANE SVC PACIFIC TEST AND BALANCE, INC. PAN-PACIFIC MECHANICAL, LLC PARAGON MECHANICAL INC PATRIOT CONTRACTING, INC. PERFORMANCE AIR SERVICE, INC. PETERSON MECHANICAL, INC. PIONEER ROOFING ORGANIZATION POMI MECHANICAL INC. PRECISION CAD SERVICES, INC. PRIME MECHANICAL SERVICE, INC. PROJECT BUILT, INC. QUALTECH MECHANICAL, INC. R E MILANO PLUMBING CORP. R J MECHANICAL, INC RAY L HELLWIG MECH REACO HEATING & A/C RECIP L162 RECIP-SASMI RMI MECHANICAL, INC. RODRIGUEZ SHEET METAL RS ANALYSIS, INC. RVTDESK, INC. RYMAC, INC. S & H CONSTRUCTION, INC. SAL J ACOSTA MFG CO INC SCHAFERS S/M & MFG CO SERVICE METAL PROD INC SHEET METAL WRKS LU 104 SHELDON MECHANICAL SILICON VALLEY MECHANICAL, INC SIMPSON SHEET METAL, INC. SMITH MECHANICAL-ELECT.-PLBG SMW 104 BAY AREA IND TRAIN FUN SOUTHLAND INDUSTRIES SOUTHWEST DESIGN & SUPPLY CO. STANDARD S/M & MARINE STATE OF CA. DEPT. OF CORRECT. STATE SHEET METAL WORKS STUMBAUGH & ASSOCIATES, INC. SUPERIOR MECH. SERVICES, INC. T.A.B.C.O. INC THE TIN MAN THERMA, LLC THERMAL MECHANICAL, INC. TRADEWINDS COOLING, LLC VAL'S PLUMBING VAN MULDER SHEET METAL VENTEC VERDEGAAL HEATING INC WCASM INC, DBA WEST COAST ASM WEST COAST FIRESTOPPING, INC. WEST COAST MECHANICAL WEST COAST TEST AND BALANCE WESTCAL DESIGN AND BUILD, INC. WESTERN ALLIED MECHANICAL, INC YOUR WARM FRIEND,INC.