2017-10-30T14:07:55-05:00 2016-12-31 611436956 NOVAK FRANCELLA LLC ONE PRESIDENTIAL BLVD SUITE 330 BALA CYNWYD PA 19004 990 2016-01-01 136162404 LOCAL 812 HEALTH FUND LOCA 5163031455 445 NORTHERN BLVD GREAT NECK NY 11021 EDWARD WEBER TRUSTEE 5163031455 2017-10-30 1 Louis Verzella CPA P00360279 6106689400 2017-10-25 162.211.205.39 2017-10-30 14:06:37 ED P A96940F3BC1CB41A42F1C40DCB182A9E8131B64B A96940F3BC1CB41A42F1C40DCB182A9E8131B64B 2016 2021-01-29 14:40:06Z EDWARD WEBER 445 NORTHERN BLVD GREAT NECK NY 11021 49216346 0 X N/A X 1945 NY TO PROVIDE HOSPITALIZATION, DRUG, DENTAL, LIFE, VISION, DISABILITY AND OTHER BENEFITS TO ELIGIBLE PARTICIPANTS AND COVERED DEPENDENTS. 7 0 3695 0 0 0 0 0 47416038 48148163 1167579 1068183 0 0 48583617 49216346 0 0 49136212 46690422 291429 268374 0 0 0 580931 1254760 50008572 48213556 -1424955 1002790 40126875 41794925 10649927 9506784 29476948 32288141 TO PROVIDE HOSPITALIZATION, DRUG, DENTAL, LIFE, VISION, DISABILITY AND OTHER BENEFITS TO ELIGIBLE PARTICIPANTS AND COVERED DEPENDENTS. 0 0 TO PROVIDE HOSPITALIZATION, DRUG, DENTAL, LIFE, VISION, DISABILITY AND OTHER BENEFITS TO ELIGIBLE PARTICIPANTS AND COVERED DEPENDENTS. 0 0 0 0 0 0 0 0 0 1 0 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 0 1 X 8 0 3695 1 0 0 0 0 0 0 X 7 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 X BOARD OF TRUSTEES LOCAL 812 HEALTH FUND 5163031455 445 NORTHERN BLVD GREAT NECK NY 11021 EDWARD WEBER TRUSTEE 5.00 40.00 X 0 194212 24179 JOSEPH VITTA TRUSTEE 5.00 40.00 X 0 154317 24179 JOHN ULRICH TRUSTEE (P) 5.00 40.00 X 0 18507 4330 ANGEL MARTINEZ TRUSTEE 5.00 40.00 X 0 117007 24179 JOHN VISCONTI TRUSTEE 5.00 40.00 X 0 154845 24179 JAMES SURDI TRUSTEE 5.00 40.00 X 0 136616 24179 LAWRENCE DEBELLIS TRUSTEE (P) 5.00 40.00 X 0 13385 10960 THOMAS STAROPOLI TRUSTEE 5.00 40.00 X 0 76671 6175 JEFF KNATZ TRUSTEE 5.00 40.00 X 0 35671 6175 JAMES SCARPATI CONTROLLER 20.00 20.00 X 76671 76671 24180 76671 977902 172715 0 0 1 0 MAGNACARE 1600 STEWART AVE WESTBURY NY 11590 PROVIDER NETWORK ADMIN 1424093 CROSSROADS HEALTHCARE MGT LLC 2556 ARTHUR KILL ROAD STATEN ISLAND NY 10309 CONTRACT ADMIN 1001126 PROSCRIPT PHARMACY MGT LLC 2556 ARTHUR KILL ROAD STATEN ISLAND NY 10309 RX ADMIN 559403 CARY KANE LLP 1350 BROADWAY SUITE 1400 NEW YORK NY 10018 LEGAL 315971 THE SEGAL COMPANY 333 W 34TH STREET NEW YORK NY 10001 BENEFIT CONSULTING 118780 6 EMPLOYER CONTRIBUTIONS 900099 46709060 46709060 STOP LOSS REIMBURSEMENTS 900099 647423 647423 MEDICARE PART D SUBSIDY 900099 506704 506704 COBRA CONTRIBUTIONS 900099 284976 284976 48148163 1068183 1068183 49216346 48148163 0 1068183 46690422 199126 21670 29694 17884 463105 125341 81123 118780 48873 25435 32394 21838 10353 24050 GOVERNMENT FEES MANDATE 303468 48213556 38893 269845 2887730 1777366 287732 261247 158924 153569 15708 5355 34948366 37835223 1948446 1645889 40126875 41794925 63338 65984 10586589 9440800 10649927 9506784 X 0 0 0 0 29476948 32288141 29476948 32288141 40126875 41794925 1002790 1808403 0 X X 0 1 X 1 0 98115 93476 4639 60809 60093 716 5355 BENEFITS PAYABLE & CLAIMS INCURRED BUT NOT REPORTED 9440800 9440800 X 50943626 1808403 1808403 49135223 81123 81123 49216346 49278222 1145789 1145789 48132433 81123 81123 48213556 Part X, Line 2: The Plan obtained its determination letter on April 20, 1993, in which the Internal Revenue Service stated that the Plan, as then designed, was in compliance with the applicable requirements of Section 501(c)(9) of the Internal Revenue Code, and was, therefore, exempt from Federal income taxes. The Plan has been amended since receiving the determination letter. The Plan's Administrator and the Plan's counsel believe that the Plan is currently designed and being operated in compliance with the applicable requirements of the Internal Revenue Code. 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 if the Plan has taken an uncertain position that, more likely than not, would not be sustained upon examination by the U.S. Federal, state, or local taxing authorities. The Plan is subject to routine audits by taxing jurisdictions; however, there are currently no audits for any tax periods in progress. Typically, plan tax years will remain open for three years; however, this may differ depending upon the circumstances of the Plan. Part XII, Line 2d - Other Adjustments: CHANGE IN BENEFIT OBLIGATION 1,145,789. 0 0 0 EDWARD WEBER TRUSTEE 0 194212 0 0 0 0 0 10920 0 13259 0 218391 0 0 JOSEPH VITTA TRUSTEE 0 154317 0 0 0 0 0 10920 0 13259 0 178496 0 0 JOHN VISCONTI TRUSTEE 0 154845 0 0 0 0 0 10920 0 13259 0 179024 0 0 JAMES SURDI TRUSTEE 0 136616 0 0 0 0 0 10920 0 13259 0 160795 0 0 JAMES SCARPATI CONTROLLER 76671 76671 0 0 0 0 5460 5460 6630 6630 88761 88761 0 0 FORM 990, PART V, LINE 2A THIS LINE INCLUDES 3 PAID EMPLOYEES AND 3,692 PARTICIPANTS THAT RECEIVED A TAXABLE LIFE INSURANCE BENEFIT. Form 990, Part VI, Section A, line 8b THERE ARE NO COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE BOARD. Form 990, Part VI, Section B, line 11b THE FUND'S INDEPENDENT ACCOUNTANT PREPARES THE FORM 990. THE 990 IS GIVEN TO THE BOARD OF TRUSTEES, WHO REVIEW IT WITH THE CONTROLLER, THE FUND'S ACCOUNTANT AND COUNSEL. Form 990, Part VI, Section C, line 19 THE FUND'S DOCUMENTS , POLICIES AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AND MAY BE EXAMINED AT THE FUND OFFICE. Form 990, Part XII, Line 2c: THE FUND'S BOARD OF TRUSTEES ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR. SDBWU LOCAL 812 RETIREMENT PLAN 445 NORTHERN BLVD GREAT NECK NY 11021 135660090 PROVIDES RETIREMENT BENEFITS TO ITS MEMBERS NY 501(A) 0 SDBWU LOCAL 812 IBT 445 NORTHERN BLVD GREAT NECK NY 11021 135045803 LABOR ORGANIZATION NY 501(C)(5) 0 JOINT COUNCIL NO 16 265 WEST 14TH STREET NEW YORK NY 10011 135505746 LABOR ORGANIZATION NY 501(C)(5) 0 COCA COLA PEPSI CLARE ROSE ABNY MEADOWBROOK DIST UNION BEER DISTRIBUTORS PHOENIX BEVERAGE CANADA DRY PEPSI MT VERNON OAK BEVERAGE MANHATTAN BEER BETT-A-WAY BEV AMERICAN COMPRESSED BOENING BROS SNAPPLE DISTRIBUTORS BEEHIVE LOBO BETT-A-WAY TRAFFIC CDNY MED DED PEPSI SECURITY IPPOLITO DIST BAYVIEW BEVERAGE PELHAM BAY BEV BAILEY DIST INC HUDSON INSURANCE CO EAST HILLS BEV J Wild BEVERAGE CORP BROOKLYN EXPRESS TMJ BEV COLONIAL BEV GOOD-O DITMARS DIST JOINT COUNCIL CO-OP CITY BEV SUNSET BEV TRIBECA BEV A J A BEVERAGE BEN DARA BENSON BROOKLYN HEIGHTS GALBO BEVERAGE TRM BEV FLATLANDS BEV SIBEN AND SIBEN LLP MADERA DIST MEEKER BEVERAGE WJD BEV KJL DISTRIBUTOR INC MIDWOOD BEV PJ BEV HOYT BEV ZANDRA DISTRIBUTORS INC Quinco BEVERAGE DISTRIBUTORS INC BROOK BEV ROLEO BEVERAGE MALBA BEV 4 J'S BEVERAGE WADE JYM BEV RED BEV NELCY BEV D & B BEV ALEGNA DIST BJ DIST BW BEV BLUE SKY BEV CAMBRIDGE BEV DAVID SKYWAY DCT BEV DFG BEVERAGE INC DIDIT BEVERAGE G & N BEV KAM BEV KAP BEVERAGE KATHICO DIST Kenro DISTRIBUTOR INC LETTA BEVERAGE MALEX BEVERAGE INC PRINCE BEV SEASIDE BEVERAGE SHANKEN BEV SOUTH BRONX BEV TJD BEV TOWER DISTRIBUTOR AL CAPELLAN BEV DIST GVM BEVERAGE DISTRIBUTOR INC JENCON BEV REBECCA BEV TJC BEVERAGE TOMKINS SQUARE BRIDGEVIEW BEV TM BEV WHITESTONE SALES SODAMAN 44 WAKEFIELD PROSPECT DIST NEXT LEVEL DIST M&C BEV F&F BEVERGAE LPL BEV DANTE BEV jackson Heights DISTRIBUTORS INC SHERMAN BEV TKO DIST PJ BEV G & M BEV 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 SOFT DRINK BWERY WRKERS & DELIVERY EMPL IND'L EMPL WRHMEN HLPR & MISC N 49325 ACCRUAL BASIS SOFT DRINK BWERY WRKERS & DELIVERY EMPL IND'L EMPL WRHMEN HLPR & MISC K 31597 ACCRUAL BASIS