2014-11-16T12:10:19-06:00 2013-12-31 510545975 PETER DECARLO CPA PLLC 112 WEST 34TH STREET 18TH FLOOR NEW YORK NY 10120 990 2013-01-01 160915820 UFCW LOCAL ONE HEALTH CARE FUND UFCW 3157979600 5911 AIRPORT ROAD ORISKANY NY 13424 FRANK C DERISO TRUSTEE 3157979600 2014-11-16 1 PETER DECARLO CPA P00851470 2129464907 X 2013 2015-11-30 17:44:51Z FRANK C DERISO 5911 AIRPORT ROAD ORISKANY NY 13424 76984635 0 X WWW.UFCWONE.ORG X 1959 NY PROVIDE CERTAIN HEALTH AND WELFARE BENEFITS TO PLAN PARTICIPANTS. 8 0 27 0 0 0 0 0 66997823 69843646 979510 1308445 0 0 67977333 71152091 0 0 55712529 72838627 1217838 1227207 0 0 0 1219448 1435142 58149815 75500976 9827518 -4348885 48387912 42490118 1010400 374610 47377512 42115508 THE OBJECTIVE OF THE FUND IS TO PROVIDE CERTAIN HEALTH AND WELFARE BENEFITS TO ELIGIBLE PARTICIPANTS, WHO ARE MEMBERS OF UFCW DISTRICT UNION LOCAL ONE, AND THEIR COVERED DEPENDENTS. 0 0 THE PLAN PROVIDED CERTAIN HEALTH AND WELFARE BENEFITS TO APPROXIMATELY 12,900 ELIGIBLE PARTICIPANTS AND THEIR COVERED DEPENDENTS. 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 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 7 0 1 27 1 0 0 0 0 0 0 X 8 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 0 0 0 X ANDREA GOLDBERGER 3157979600 5911 AIRPORT ROAD ORISKANY NY 13424 FRANK C DERISO TRUSTEE 1.00 X 0 261581 22806 ERIC A GLATHAR TRUSTEE 1.00 X 0 201889 21212 GREGORY P GOREA TRUSTEE 1.00 X 0 187124 21047 DONALD ELIASON TRUSTEE 1.00 X 0 137542 19442 JOHN BARRETT TRUSTEE 1.00 X 0 0 0 RAYMOND WARDYNSKI TRUSTEE 1.00 X 0 0 0 I STEPHEN DAVIS TRUSTEE 1.00 X 0 0 0 KRISTINE WYDRO TRUSTEE 1.00 X 0 0 0 ANDREA GOLDBERGER ADMINISTRATIVE DIRECTOR 22.00 X 131864 0 30096 MICHAEL CIANCAGLINI EMPLOYEE 40.00 X 109445 0 28517 241309 788136 143120 2 0 1 0 SLEVIN & HART PC 1625 MASSACHUSETTS AVENUE NW WASHINGTON DC 20036 LEGAL 224319 1 EMPLOYER CONTRIBUTIONS 525100 67300740 67300740 PARTICIPANT CONTRIBUTIONS 525100 2488535 2488535 LIQUIDATED DAMAGES 525100 54371 54371 69843646 1266348 1266348 5871141 3500 5832544 0 38597 3500 42097 42097 71152091 69843646 0 1308445 72838627 844167 126127 189794 67119 230038 56000 107640 204201 124481 332452 157786 33070 26367 14186 54570 OPERATIONS EXPENSE 51613 PRINTING & PUBLICATIONS 38106 FIELD AUDITS 4632 75500976 10145 7605 10178912 3364887 6848751 8043519 268010 295372 2035428 1991220 12704 44208 29918784 29583921 1150606 1150606 48387912 42490118 185624 210584 824776 164026 1010400 374610 X 0 0 0 0 47377512 42115508 47377512 42115508 48387912 42490118 -4348885 -913119 0 X X 0 1 X 1 0 28682 28682 0 670899 665742 5157 1335847 1296796 39051 44208 DUE TO BROKER FOR SECURITIES PURCHASED 5706 DUE TO UFCW LOCAL ONE PENSION FUND 158320 164026 70131332 -913119 -913119 71044451 107640 107640 71152091 75393336 0 75393336 107640 107640 75500976 X 0 0 0 FRANK C DERISO TRUSTEE 0 261581 0 0 0 0 0 9899 0 12907 0 284387 0 0 ERIC A GLATHAR TRUSTEE 0 201889 0 0 0 0 0 8305 0 12907 0 223101 0 0 GREGORY P GOREA TRUSTEE 0 187124 0 0 0 0 0 8141 0 12906 0 208171 0 0 DONALD ELIASON TRUSTEE 0 137542 0 0 0 0 0 6820 0 12622 0 156984 0 0 ANDREA GOLDBERGER ADMINISTRATIVE DIRECTOR 131864 0 0 0 0 0 10716 0 19380 0 161960 0 0 0 FORM 990, PART VI, SECTION A, LINE 8B NO COMMITTEE HAS THE AUTHORITY TO ACT ON BEHALF OF THE BOARD OF TRUSTEES FORM 990, PART VI, SECTION B, LINE 11 NO REVIEW WAS CONDUCTED. FORM 990, PART VI, SECTION C, LINE 19 DISCLOSURES REQUIRED BY LAW ARE AVAILABLE TO THE PUBLIC AT THE FUND'S OFFICE, UPON REQUEST. 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. THERE WAS NO CHANGE DURING THE TAX YEAR IN EITHER THE FUND'S OVERSIGHT OR SELECTION PROCESS. UFCW DISTRICT UNION LOCAL ONE 5911 AIRPORT ROAD ORISKANY NY 13424 150559586 LABOR UNION NY 501(C)(5) 0 UFCW LOCAL ONE PENSION FUND 5911 AIRPORT ROAD ORISKANY NY 13424 166144007 PENSION PLAN NY 501(A) 0 UFCW LOCAL ONE 401(K) SAVINGS PLAN 5911 AIRPORT ROAD ORISKANY NY 13424 166184130 PENSION PLAN NY 501(A) 0 LUTHERAN HOMES ADIRONDACK MEDICAL CENTER ST ELIZABETH MEDICAL CENTER TOPS MARKETS INC EMPIRE MERCHANTS NORTH ALBANY KRAFT FOODS INC GREAT AMERICAN STORES HERITAGE HEALTH CARE CENTER SILGAN CONTAINERS MANUFACTURING CORP SAHLEN PACKING CORP G&L DAVIS MEAT CO HOMETOWN MARKETS LLC THORNES OF WARREN SPECIALTY STEAK EMPIRE MERCHANTS NORTH BUFFALO SHOP RITE SUPERMARKETS INC CHANATRY'S FRENCH ROAD MARKET ZWEIGLES INC GIANT EAGLE INC SODEXO INC WELCH FOODS INC CARRIER COACH BREENS FAMILY INC FORT'S GROCERY INC SMITH PACKING COMPANY WALTON'S BIG M HOFMANN SAUSAGE CO INC OLD WORLD PROVISION CO INC LR BRASS INC COUDERSPORT JUBILEE SMYD CORP DIVERSE FOOD PRODUCTS LLC PROVIDENTIAL FOODS CORP VANCHLOR CO FRANK WARDYNSKI & SONS INC PARKVIEW SUPERMARKET PORT ALLEGANY JUBILEE TN HARVEY INC PAWLAKS FOOD CENTER FILLMORE JUBILEE GALETON IGA INDELICATO'S MARKET FIBERCELL PACKAGING LLC BIG V CORP MILWARD ALLOYS INC 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 1 UFCW DISTRICT UNION LOCAL ONE P 301554 ALLOCATION UFCW LOCAL ONE PENSION FUND Q 862266 ALLOCATION UFCW LOCAL ONE 401(K) SAVINGS PLAN Q 230912 ALLOCATION LUTHERAN HOMES S 1337055 CONTRACT ADIRONDACK MEDICAL CENTER S 1144117 CONTRACT ST ELIZABETH MEDICAL CENTER S 1100574 CONTRACT UFCW DISTRICT UNION LOCAL ONE S 544788 CONTRACT TOPS MARKETS INC S 49685753 CONTRACT EMPIRE MERCHANTS NORTH ALBANY S 1646445 CONTRACT KRAFT FOODS INC S 1304469 CONTRACT GREAT AMERICAN STORES S 732241 CONTRACT HERITAGE HEALTH CARE CENTER S 545815 CONTRACT SILGAN CONTAINERS MANUFACTURING CORP S 765567 CONTRACT SAHLEN PACKING CORP S 658098 CONTRACT G&L DAVIS MEAT CO S 669988 CONTRACT HOMETOWN MARKETS LLC S 464164 CONTRACT THORNES OF WARREN S 595512 CONTRACT SPECIALTY STEAK S 506501 CONTRACT EMPIRE MERCHANTS NORTH BUFFALO S 467552 CONTRACT SHOP RITE SUPERMARKETS INC S 566528 CONTRACT CHANATRY'S FRENCH ROAD MARKET S 346277 CONTRACT ZWEIGLES INC S 234852 CONTRACT GIANT EAGLE INC S 304586 CONTRACT SODEXO INC S 215790 CONTRACT WELCH FOODS INC S 233758 CONTRACT CARRIER COACH S 290687 CONTRACT BREENS FAMILY INC S 166911 CONTRACT FORT'S GROCERY INC S 202466 CONTRACT SMITH PACKING COMPANY S 172313 CONTRACT WALTON'S BIG M S 180938 CONTRACT HOFMANN SAUSAGE CO INC S 246304 CONTRACT OLD WORLD PROVISION CO INC S 217549 CONTRACT LR BRASS INC S 140706 CONTRACT COUDERSPORT JUBILEE S 157231 CONTRACT SMYD CORP S 120826 CONTRACT DIVERSE FOOD PRODUCTS LLC S 118018 CONTRACT PROVIDENTIAL FOODS CORP S 118676 CONTRACT VANCHLOR CO S 96566 CONTRACT FRANK WARDYNSKI & SONS INC S 101870 CONTRACT PARKVIEW SUPERMARKET S 146098 CONTRACT PORT ALLEGANY JUBILEE S 53683 CONTRACT TN HARVEY INC S 63352 CONTRACT PAWLAKS FOOD CENTER S 64328 CONTRACT FILLMORE JUBILEE S 57557 CONTRACT GALETON IGA S 58534 CONTRACT INDELICATO'S MARKET S 51324 CONTRACT FIBERCELL PACKAGING LLC S 165847 CONTRACT BIG V CORP S 156450 CONTRACT MILWARD ALLOYS INC S 235644 CONTRACT