BLUE LAKE RANCHERIA EMPLOYEE BENEFITS TR: Form 990, tax year 2017
View the entire original 990 at ProPublica ↗
- Organization
- BLUE LAKE RANCHERIA EMPLOYEE BENEFITS TR (EIN 80-0928592)
- Tax period
- 2017-01-01 to 2017-12-31
- Filed
- 2018-02-16
- IRS object ID
- 201820479349301267
- Schema version
- 2017v2.2
- 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 | 2018-02-16T12:57:23-08:00 | ReturnTs |
| Tax Period End | 2017-12-31 | 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 | 2017-01-01 | 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 | TRUSTEE | PersonTitleTxt |
| Phone | 7077869798 | PhoneNum |
| Signature | 2018-02-13 | SignatureDt |
| Discuss With Paid Preparer | Yes (true) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | STACEY R EDGMON | PreparerPersonNm |
| PTIN | P00128058 | PTIN |
| Phone | 7077869798 | PhoneNum |
| Preparation | 2018-02-14 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2017 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | PHILIP AYCOCK | PrincipalOfficerNm |
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) |
|---|---|---|
| Gross Receipts | $1,617,123 | 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 | $1,417,495 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $1,549,676 | CYProgramServiceRevenueAmt |
| PY Investment Income | $48,061 | PYInvestmentIncomeAmt |
| CY Investment Income | $66,142 | CYInvestmentIncomeAmt |
| CY Other Revenue | $1,305 | CYOtherRevenueAmt |
| PY Total Revenue | $1,465,556 | PYTotalRevenueAmt |
| CY Total Revenue | $1,617,123 | CYTotalRevenueAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $993,085 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $1,236,046 | 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 | $407,005 | PYOtherExpensesAmt |
| CY Other Expenses | $333,252 | CYOtherExpensesAmt |
| PY Total Expenses | $1,400,090 | PYTotalExpensesAmt |
| CY Total Expenses | $1,569,298 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $65,466 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $47,825 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $1,444,819 | TotalAssetsBOYAmt |
| Total Assets EOY | $1,564,206 | TotalAssetsEOYAmt |
| Total Liabilities EOY | $1,565 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $1,444,819 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $1,562,641 | 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 |
| Temp Or Permanent Endowments | false | TempOrPermanentEndowmentsInd |
| 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 With Officer Ent | false | BusinessRlnWithOfficerEntInd |
| 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 |
| 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
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | PHILIP AYCOCK | PersonNm |
| Title | TRUSTEE | TitleTxt |
| Individual Trustee Or Director | Yes (X) | IndividualTrusteeOrDirectorInd |
| Reportable Comp From Org | $0 | ReportableCompFromOrgAmt |
| Reportable Comp From Rltd Org | $0 | ReportableCompFromRltdOrgAmt |
| Other Compensation | $0 | OtherCompensationAmt |
| 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
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | PREMIUM INCOME | Desc |
| Total Revenue Column | $1,549,676 | TotalRevenueColumnAmt |
| Exclusion | $1,549,676 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $1,549,676 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $66,142 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $102 | RelatedOrExemptFuncIncomeAmt |
| Exclusion | $66,040 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | REFUNDS | Desc |
| Total Revenue Column | $1,305 | TotalRevenueColumnAmt |
| Exclusion | $1,305 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $1,305 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,617,123 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $102 | RelatedOrExemptFuncIncomeAmt |
| Exclusion | $1,617,021 | ExclusionAmt |
Benefits To Members BenefitsToMembersGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,236,046 | TotalAmt |
| Program Services | $1,236,046 | ProgramServicesAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $22,212 | TotalAmt |
| Management And General | $22,212 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $175,619 | TotalAmt |
| Program Services | $175,619 | ProgramServicesAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| ADMINISTRATION | $72,493 | $72,493 | |
| MEMBERSHIPS | $30,094 | $30,094 | |
| PROFESSIONAL FEES | $25,325 | $25,325 | |
| BANK CHARGES | $6,365 | $6,365 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,144 | TotalAmt |
| Program Services | $231 | ProgramServicesAmt |
| Management And General | $913 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,569,298 | TotalAmt |
| Program Services | $1,520,848 | ProgramServicesAmt |
| Management And General | $48,450 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $134,849 | BOYAmt |
| EOY | $184,238 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,309,970 | BOYAmt |
| EOY | $1,379,968 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,444,819 | BOYAmt |
| EOY | $1,564,206 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $1,565 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $1,565 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Org Does Not Follow SFAS117 | Yes (X) | OrgDoesNotFollowSFAS117Ind |
Rtn Earn Endowment Incm Oth Fnds RtnEarnEndowmentIncmOthFndsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,444,819 | BOYAmt |
| EOY | $1,562,641 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,444,819 | BOYAmt |
| EOY | $1,562,641 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,444,819 | BOYAmt |
| EOY | $1,564,206 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $47,825 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $69,997 | 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 |
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