2017-08-29T09:36:27-05:00 2016-10-31 420714325 RSM US LLP 117 E MAIN ST STE 210 GALESBURG IL 61401 990 2015-11-01 367042729 RFMS INC MEDICAL BENEFIT PLAN TRUST RFMS 3093431550 285 SOUTH FARNHAM STREET GALESBURG IL 61401 RONALD WILSON TRUSTEE 3093431550 2017-08-07 1 MICHAEL BASS P00458970 3093428026 2015 2021-01-29 14:40:06Z RONALD WILSON 285 SOUTH FARNHAM STREET GALESBURG IL 61401 10736500 0 X N/A X 1988 IL TO PROVIDE MEDICAL, SHORT-TERM DISABILITY & DEATH BENEFITS FOR ELIGIBLE EMPLOYEES & DEPENDENTS. 2 2 0 2 0 0 0 0 9948158 10726776 7184 9724 0 0 9955342 10736500 0 0 7034727 8113412 0 0 0 0 0 1252743 1282564 8287470 9395976 1667872 1340524 2725487 4000286 823735 753757 1901752 3246529 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: RFMS, INC., LTC SUPPORT SERVICES, LLC, COMMUNITY LIVING OPTIONS, INC., FRANCES HOUSE, INC., UNLIMITED DEVELOPMENT, INC., KENSINGTON OF GALESBURG, INC., ACHIEVEMENT UNLIMITED, INC., PINNACLE OPPORTUNITIES, INC., PIONEER CONCEPTS, INC., RESIDENTIAL ALTERNATIVES OF ILLINOIS, INC., DESERT HEALTHCARE FACILITIES, INC., FLORIDA LIVING OPTIONS, INC., ILLINI STATE BANK AND HIGHLAND ESTATES RESORT, LLC. 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 0 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 X 2 2 1 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 DONALD E FIKE TRUSTEE 1.00 X 0 0 0 RONALD WILSON TRUSTEE 1.00 X 0 0 0 0 0 0 0 0 0 0 RSM US LLP 5155 PAYSPHERE CIRCLE CHICAGO IL 60674 ACCOUNTING 100600 1 X PLAN CONTRIBUTIONS 900001 10726776 10726776 10726776 9724 9724 10736500 10726776 0 9724 8113412 1920 98567 INSURANCE PREMIUMS 854295 ADMINISTRATIVE EXPENSES 327782 9395976 2116907 2018976 10353 1510267 296329 159540 301898 311503 2725487 4000286 77396 48851 6183 9825 740156 695081 823735 753757 X 0 0 0 0 1901752 3246529 1901752 3246529 2725487 4000286 1340524 4253 0 X X 0 1 X 1 0 0 BENEFITS PAYABLE 695081 695081 X 10740753 4253 4253 10736500 0 10736500 9441051 45075 45075 9395976 0 9395976 PART X, LINE 2: 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. WITH FEW EXCEPTIONS, THE PLAN IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY THE U.S. FEDERAL TAX AUTHORITIES FOR YEARS BEFORE 2013. PART XII, LINE 2D - OTHER ADJUSTMENTS: DECREASE IN ESTIMATED OBLIGATIONS FOR CLAIMS INCURRED BUT NOT REPORTED 45,075. RFMS INC THE PLAN SPONSOR OF RFMS, INC. MEDICAL BENEFIT PLAN TRUST IS RFMS, INC. 239905 PREMIUMS WERE PAID BY RFMS, INC. IN THE AMOUNT OF $239,905 TO THE RFMS, INC. MEDICAL BENEFIT PLAN TRUST FOR THE YEAR ENDING OCTOBER 31, 2016. THE PREMIUM AMOUNT FOR RFMS, INC. PARTICIPANTS IS THE SAME AS THAT CHARGED TO ALL OTHER PARTICIPANTS IN THE PLAN. RFMS, INC. RECEIVES NO MONEY FROM THE RFMS, INC., MEDICAL BENEFIT PLAN TRUST. DONALD E. FIKE, A TRUSTEE OF THE RFMS, INC. MEDICAL BENEFIT PLAN TRUST, OWNS 100% OF RFMS, INC. RONALD WILSON, A TRUSTEE OF THE RFMS, INC. MEDICAL BENEFIT PLAN TRUST, IS THE CHIEF FINANCIAL OFFICER OF RFMS, INC. THE RFMS, INC., MEDICAL BENEFIT PLAN TRUST PAYS NO COMPENSATION TO THE TRUSTEES OR TO RFMS, INC. 0 FORM 990, PART V, LINE 1A: THE THIRD PARTY ADMINISTRATOR FOR THE RFMS, INC. MEDICAL BENEFIT PLAN TRUST FILES JOINT FORMS 1099 FOR ALL PLANS UNDER THEIR ADMINISTRATION. FORM 990, PART VI, SECTION A, LINE 2 RONALD WILSON AND DONALD E. FIKE EACH ARE PARTNERS AND/OR SHAREHOLDERS IN LB PROPERTIES, INC. (AN S-CORPORATION), AND EDWIN ENTERPRISES, LLC (A PARTNERSHIP). DONALD E. FIKE OWNS A GREATER THAN 35% INTEREST IN BOTH OF THESE ENTITIES. RONALD WILSON AND DONALD E. FIKE ARE ALSO CO-OWNERS OF NORTH STREET APARTMENTS, A 14-UNIT APARTMENT BUILDING . RONALD WILSON AND DONALD E. FIKE ALSO HAVE AN INDIRECT BUSINESS RELATIONSHIP THROUGH THEIR INDIRECT OWNERSHIP INTEREST IN GALESBURG CILA, LLC, GALESBURG CILA #2, LLC, NORTHWEST ILLINOIS CILA, LLC AND MORGAN COUNTY HOMES, LLC. THE RFMS, INC. MEDICAL BENEFIT PLAN TRUST MAKES NO PAYMENTS TO LB PROPERTIES, INC., EDWIN ENTERPRISES, LLC, NORTH STREET APARTMENTS, GALESBURG CILA, LLC, GALESBURG CILA #2, LLC, NORTHWEST ILLINOIS CILA, LLC OR MORGAN COUNTY HOMES, LLC. FORM 990, PART VI, SECTION A, LINE 8A THE NATURE OF THE ENTITY DOES NOT REQUIRE REGULARLY SCHEDULED AND STRUCTURED MEETINGS OF THE TRUSTEES. 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 TRUSTEES OVERSEE THE RECEIPT OF PREMIUMS AND THE PAYMENT OF BENEFITS AS REQUIRED, AND ALSO MAKE 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 OF THE TRUSTEES. 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 TRUSTEES OVERSEE THE RECEIPT OF PREMIUMS AND THE PAYMENT OF BENEFITS AS REQUIRED, AND ALSO MAKE CERTAIN THAT THE THIRD PARTY ADMINISTRATOR FULFILLS ITS RESPONSIBILITIES. FORM 990, PART VI, SECTION B, LINE 11 EACH 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 TRUSTEES RECEIVE NO PAYMENTS OR COMPENSATION FROM THE RFMS, INC. MEDICAL BENEFIT PLAN TRUST. THEY ARE EMPLOYED BY RFMS, INC. RFMS, INC. PAYS THE SAME PREMIUMS AS ALL OTHER PARTICIPATING ENTITIES IN THE PLAN. RFMS, INC. PROVIDES ADMINISTRATIVE SERVICES TO THE PLAN FREE OF CHARGE. FORM 990, PART VII, SECTION A, LINE 1A, COLUMN B: THE TRUSTEES DEVOTE 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 EACH TRUSTEE NORMALLY DEVOTES LESS THAN ONE HOUR PER WEEK TO THE RFMS, INC. MEDICAL BENEFIT 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 (92.0%) OF THE CONTRIBUTIONS TO THE RFMS, INC. MEDICAL BENEFIT 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. 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 RFMS INC LTC SUPPORT SERVICES LLC KENSINGTON OF GALESBURG INC HIGHLAND ESTATES RESORT LLC ILLINI STATE BANK 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 SCHEDULE R, PART IV: LB PROPERTIES, INC. (EIN: 37-1272792) IS THE SOLE MEMBER OF HIGHLAND ESTATES RESORT, LLC.