2016-03-12T10:22:10-06:00 2015-05-31 470900880 CALIBRE CPA GROUP PLLC 7501 WISCONSIN AVENUE SUITE 1200 WEST BETHESDA MD 20814 990 2014-06-01 204570305 LONG TERM CARE WORKERS HEALTH TRUST FUND LONG 8776985829 2910 BEVERLY BOULEVARD LOS ANGELES CA 90057 SAMUEL COOK TRUSTEE 8776985829 2016-03-12 1 SCOTT E HALLBERG CPA P01081188 2023319880 2014 2016-08-17 19:52:53Z SAMUEL COOK 2910 BEVERLY BOULEVARD LOS ANGELES CA 90057 3229770 0 X N/A X 2006 CA THE TRUST WAS ESTABLISHED TO MAINTAIN THE LONG TERM CARE WORKERS HEALTH PLAN. THE PLAN WAS CREATED FOR THE EXCLUSIVE BENEFIT OF ELIGIBLE LONG TERM CARE WORKERS. THE PLAN PROVIDES HEALTH BENEFITS (MEDICAL, DENTAL, AND VISION) TO PARTICIPATING EMPLOYEES IN THE IN-HOME SUPPORTIVE SERVICES INDUSTRY OF CALIFORNIA, WHOSE EMPLOYERS ARE REQUIRED, BY CONTRACT, TO PAY CONTRIBUTIONS TO THE TRUST. 4 1 0 0 0 0 0 0 8728794 3214956 20458 14799 47220 15 8796472 3229770 0 0 8656041 3448984 0 0 0 0 0 713876 352179 9369917 3801163 -573445 -571393 10151116 9425355 175399 21031 9975717 9404324 SEE SCHEDULE O FOR DETAILS. 0 0 THE PLAN PROVIDES HEALTH BENEFITS SUCH AS MEDICAL, DENTAL, AND VISION TO PARTICIPATING EMPLOYEES IN THE IN-HOME SUPPORTIVE SERVICES INDUSTRY OF CALIFORNIA. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 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 3 0 1 0 0 0 0 0 0 0 X 4 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 CA X PSWA 6263506900 4399 SANTA ANITA AVENUE STE 200 EL MONTE CA 91731 DAVID WERLIN TRUSTEE 1.00 X 0 103981 49598 SAMUEL COOK TRUSTEE 1.00 X 0 119113 35125 LAPHONZA BUTLER CHAIR 1.00 X 0 161723 35785 ROSA MUNDY TRSUTEE 1.00 X 0 0 0 0 384817 120508 0 0 1 0 SCHWARTZ STEINSAPIR DOHRMANN & SOMMERS 6300 WILSHIRE BOULEVARD SUITE 2000 LOS ANGELES CA 90048 LEGAL FEES 145900 ATPA 4399 SANTA ANITA AVE 200 EL MONTE CA 91731 ADMINISTRATOR FEES 118520 2 EMPLOYER CONTRIBUTIONS 900099 3215101 3215101 PARTICIPANT CONTRIBUTI 900099 -145 -145 3214956 14799 14799 MISCELLANOUS INCOME 900099 15 15 15 3229770 3214971 0 14799 3448984 102416 22000 60180 23610 38557 ADMINISTRATOR FEES 102861 OTHER EXPENSES 2555 3801163 9952149 8988414 113131 169183 3942 6917 81894 260841 10151116 9425355 175399 21031 175399 21031 X 9975717 9404324 9975717 9404324 10151116 9425355 -571393 0 X 0 1 X 0 0 0 X 3229770 0 3229770 0 3229770 3801163 0 3801163 0 3801163 PART X, LINE 2: THE PLAN IS INTENDED TO QUALIFY UNDER SECTION 501(C) (9) OF THE INTERNAL REVENUE CODE AND,THEREFORE, IS NOT SUBJECT TO INCOME TAX. THE PLAN OBTAINED A FAVORABLE TAX DETERMINATION LETTER FROM THE INTERNAL REVENUE SERVICE ON JANUARY 4, 2008, STATING THAT THE PLAN, AS THEN DESIGNED,WAS IN COMPLIANCE WITH THE APPLICABLE REQUIREMENTS OF THE INTERNAL REVENUE CODE. THE PLAN HAS ALSO RECEIVED A FAVORABLE TAX DETERMINATION LETTER FROM THE STATE OF CALIFORNIA. THE PLAN HAS BEEN AMENDED SINCE RECEIVING THE DETERMINATION LETTERS. THE PLAN SPONSOR BELIEVES THAT THE PLAN, AS AMENDED, CONTINUES TO QUALIFY AND TO OPERATE IN ACCORDANCE WITH APPLICABLE PROVISIONS OF THE INTERNAL REVENUE CODE. THEREFORE, NO PROVISION FOR FEDERAL OR CALIFORNIA INCOME TAXES HAS BEEN INCLUDED IN THE PLANS FINANCIAL STATEMENTS. AS OF MAY 31, 2015, THE STATUTE OF LIMITATIONS FOR TAX YEARS 2011 THROUGH 2013 REMAINS OPEN WITH THE U. S. FEDERAL JURISDICTION AND THE VARIOUS STATES AND LOCAL JURISDICTIONS IN WHICH THE PLAN FILES RETURNS. 0 0 0 DAVID WERLIN TRUSTEE 0 103981 0 0 0 0 0 18717 0 30881 0 153579 0 0 SAMUEL COOK TRUSTEE 0 119113 0 0 0 0 0 21440 0 13685 0 154238 0 0 LAPHONZA BUTLER CHAIR 0 161723 0 0 0 0 0 29110 0 6675 0 197508 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE TRUSTEE REVIEWS THE FORM 990 BEFORE FILING THE RETURN WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C INTERNAL PROCEDURES INCLUDE THE CONTINUOUS REVIEW OF PROCEDURES TO ENSURE COMPLIANCE. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ANY OF ITS DOCUMENTS AVAILABLE TO THE GENERAL PUBLIC. SEIU UNITED LONG-TERM CARE WORKERS LOCAL UNION NO 6434 2910 BEVERLY BLVD LOS ANGELES CA 90057 260718017 UNITE MEMBERS INTO ONE ORG. FOR THE PURPOSE OF IMPROVING WORKING CONDITIONS CA 501(C)(5) 0 DEL NORTE COUNTY - STATE OF CALIFORNIA COUNTY OF MADERA - STATE OF CALIFORNIA COUNTY OF SAN BENITO - STATE OF CALIFORNIA COUNTY OF SANTA CRUZ - STATE OF CALIFORNIA COUNTY OF VENTURA - STATE OF CALIFORNIA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0