2015-04-13T19:05:50-05:00 2014-06-30 320043599 LEGACY PROFESSIONALS LLP 311 S WACKER DRIVE STE 4000 CHICAGO IL 60606 990 2014-01-01 356045880 INDIANA AREA UFCW HEALTH AND WELFARE PLAN INDI 3172477381 5420 WEST SOUTHERN AVENUE NO 407 INDIANAPOLIS IN 46241 JOE CHORPENNING TRUSTEE 3172477381 2015-04-13 1 VICTOR ANCICH P00201493 3123680500 2014 2016-02-25 16:41:14Z X JOE CHORPENNING 5420 WEST SOUTHERN AVENUE NO 407 INDIANAPOLIS IN 46241 19641869 0 X N/A X 1968 IN PROVIDE HEALTH BENEFITS X 0 0 0 0 0 0 0 0 40422005 16686565 27297 41253 3929 1791 40453231 16729609 0 0 43865035 19488599 0 0 0 0 0 2176270 1155590 46041305 20644189 -5588074 -3914580 7495347 0 279347 0 7216000 0 X PROVIDE HEALTH BENEFITS 0 1 TO PROVIDE ACCIDENT, HEALTH, DENTAL, VISION, PRESCRIPTION DRUG, LIFE & LOSS OF TIME BENEFITS FOR ELIGIBLE PARTICIPANTS AND/OR THEIR DEPENDENTS IN ACCORDANCE WITH THE PLAN DOCUMENT AND THE SCHEDULE OF BENEFITS. 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 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 1 5 0 1 0 0 0 0 0 0 0 0 0 X 0 0 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 0 1 0 0 0 IN X HEARTLAND HEALTH AND WELLNESS FUND 9376651900 7250 POE AVENUE SUITE 300 DAYTON OH 454142547 X JOE CHORPENNING TRUSTEE - PAST 1.00 X 0 0 0 CINDY BONDAR TRUSTEE - PAST 1.00 X 0 0 0 SCOTT BARNETT TRUSTEE - PAST 1.00 X 0 0 0 MICHAEL MURDOCK TRUSTEE - PAST 1.00 X 0 0 0 MICHAEL MERRELL TRUSTEE - PAST 1.00 X 0 0 0 THOMAS CEBULKO TRUSTEE - PAST 1.00 X 0 0 0 RICHARD FITZGERALD TRUSTEE - PAST 1.00 X 0 0 0 NORA BAMMANN TRUSTEE -PAST 1.00 X 0 0 0 0 0 0 0 0 0 0 ANTHEM 220 VIRGINIA AVENUE INDIANAPOLIS IN 46204 BENEFIT CLAIMS ADMINISTRATOR 685772 ZENITH AMERICAN SOLUTIONS 5420 WEST SOUTHERN AVENUE SUITE 407 INDIANAPOLIS IN 46241 ADMINISTRATIVE SERVICES 559060 CONIFER VALUE-BASED CARE LLC 1596 WHITEHALL ROAD ANNAPOLIS MD 21409 CARE MANAGEMENT SERVICES 232707 MILLIMAN 111 MONUMENT CIRCLE SUITE 601 INDIANAPOLIS IN 46204 BENEFIT AND ACTUARIAL SERVICES 207703 REINHART BOERNER VAN DEUREN 100 NORTH WATER STREET SUITE 1700 MILWAUKEE WI 53202 LEGAL SERVICES 147343 6 EMPLOYER CONTRIBUTIONS 900099 16426363 16426363 PRESCRIPTION DRUG REBATES 900099 130926 130926 PARTICIPANT CONTRIB. 900099 129276 129276 16686565 4100 4100 2949413 2912260 37153 37153 37153 MISCELLANEOUS 900099 1791 1791 1791 16729609 16686565 0 43044 19488599 258628 78593 741114 48416 15737 6309 6335 MEMBERSHIP DUES 458 20644189 1071724 0 0 0 3225165 0 0 0 0 0 7172 0 0 2912260 0 0 0 0 279026 0 7495347 0 279347 0 279347 0 X 0 0 0 0 7216000 0 7216000 0 7495347 0 X -3914580 -3301420 X 0 1 X 1 0 0 X 16729609 0 16729609 0 16729609 20644189 0 20644189 0 20644189 PART X, LINE 2: THE PLAN IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(9) OF THE INTERNAL REVENUE CODE, EXCEPT ON NET INCOME DERIVED FROM UNRELATED BUSINESS ACTIVITIES. FOR THE PERIOD ENDED JUNE 30, 2014, THE PLAN HAS DETERMINED THAT NO INCOME TAXES ARE DUE FROM ITS ACTIVITIES. ACCORDINGLY, NO PROVISION FOR INCOME TAXES HAS BEEN RECORDED IN THE FINANCIAL STATEMENTS. THE PLAN FILES FORM 990, RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX AND FORM 5500, ANNUAL RETURN/REPORT OF EMPLOYEE BENEFIT PLAN. THE PLAN'S RETURNS ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE UNTIL THE APPLICABLE STATUE OF LIMITATION EXPIRES. CASH 2014-06-30 861597 ACTUAL 316041107 HEARTLAND HEALTH AND WELLNESS FUND 7250 POE AVENUE SUITE 300 DAYTON OH 45414 501(C)9 RECEIVABLES 2014-06-30 2557019 ACTUAL 316041107 HEARTLAND HEALTH AND WELLNESS FUND 7250 POE AVENUE SUITE 300 DAYTON OH 45414 501(C)9 PREPAID EXPENSES 2014-06-30 8625 ACTUAL 316041107 HEARTLAND HEALTH AND WELLNESS FUND 7250 POE AVENUE SUITE 300 DAYTON OH 45414 501(C)9 ACCOUNTS PAYABLE AND ACCRUED EXPENSES 2014-06-30 -125821 ACTUAL 316041107 HEARTLAND HEALTH AND WELLNESS FUND 7250 POE AVENUE SUITE 300 DAYTON OH 45414 501(C)9 1 0 0 0 1 0 0 1 0 PART I, LINE 2E: PERSON(S) INVOLVED: JOE CHORPENNING BECAME A TRUSTEE OF THE HEARTLAND HEALTH AND WELLNESS FUND SUBSEQUENT TO THE MERGER. SCHEDULE N PART I LIQUIDATION, TERMINATION OR DISSOLUTION INDIANA AREA UFCW HEALTH AND WELFARE PLAN CEASED OPERATIONS AT THE CLOSE OF BUSINESS ON JUNE 30, 2014, PURSUANT TO A MERGER AGREEMENT BETWEEN THE BOARD OF TRUSTEES OF THE INDIANA AREA UFCW HEALTH AND WELFARE PLAN AND THE BOARD OF TRUSTEES OF HEARTLAND HEALTH AND WELLNESS FUND EFFECTIVE JULY 1, 2014. FORM 990, PART III, LINE 3 INDIANA AREA UFCW HEALTH AND WELFARE PLAN CEASED OPERATIONS AT THE CLOSE OF BUSINESS ON JUNE 30, 2014, PURSUANT TO A MERGER AGREEMENT BETWEEN THE BOARD OF TRUSTEES OF THE INDIANA AREA UFCW HEALTH AND WELFARE PLAN AND THE BOARD OF TRUSTEES OF HEARTLAND HEALTH AND WELLNESS FUND EFFECTIVE JULY 1, 2014. FORM 990, PART VI, SECTION A, LINE 3 WHILE THE BOARD OF TRUSTEES RETAINS ULTIMATE RESPONSIBILITY, THEY HAVE DELEGATED THE DAY TO DAY MANAGEMENT OF THE FUND TO A THIRD PARTY ADMINISTRATOR, ZENITH AMERICAN SOLUTIONS. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF FORM 990 IS PROVIDED TO THE ENTIRE BOARD OF TRUSTEES FOR THEIR REVIEW AND APPROVAL PRIOR TO ITS FILING. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES THE INFORMATION IN QUESTION 19 AVAILABLE UPON REQUEST THROUGH THE PLAN'S THIRD PARTY ADMINISTRATOR - ZENITH AMERICAN SOLUTIONS. FORM 990, PART XI, LINE 9: TRANSFER OF NET ASSETS DUE TO MERGER -3,301,420. BOROWIAKS IGA CONTRIBUTING EMPLOYER 0 SALEM IGA CONTRIBUTING EMPLOYER 0 PERRY COUNTY MARKET PLACE CONTRIBUTING EMPLOYER 0 ROZIER'S CHESTER MARKET PLACE CONTRIBUTING EMPLOYER 0 NORRENBERNS FOODS INC CONTRIBUTING EMPLOYER 0 KROGER CENTRAL DIVISION CONTRIBUTING EMPLOYER 0 KROGER CINCINNATI DIVISION CONTRIBUTING EMPLOYER 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1