2013-03-12T18:09:11-05:00 2012-06-30 522385296 LINDQUIST LLP 5000 EXECUTIVE PARKWAY SUITE 400 SAN RAMON CA 945834210 990 2011-07-01 942541328 SHEET METAL WORKERS LOCAL 104 HEALTH CARE PLAN SHEE 9252089999 2610 CROW CANYON ROAD NO 200 SAN RAMON CA 94583 BRUCE WORD 9252089999 2013-03-12 1 JESSICA R ROSTER P01317380 9252779100 2011 2016-02-25 16:41:14Z BRUCE WORD 2610 CROW CANYON ROAD SUITE 200 SAN RAMON CA 94583 94797485 0 X N/A X 1979 CA TO PROVIDE HEALTH BENEFITS AND SUPPLEMENTAL UNEMPLOYMENT BENEFITS 16 0 48 0 0 0 0 0 71092788 77761718 4587094 1248061 395676 271055 76075558 79280834 0 0 70948834 67446448 0 0 0 0 0 3963998 4332101 74912832 71778549 1162726 7502285 52288909 57025304 27408672 24265916 24880237 32759388 TO PROVIDE HEALTH BENEFITS AND SUPPLEMENTAL UNEMPLOYEMENT BENEFITS. 0 0 PROVIDED HEALTH AND WELFARE BENEFITS AND SUPPLEMENTAL UNEMPLOYMENT BENEFITS TO PARTICIPANTS AND THEIR ELIGIBLE DEPENDENTS. 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 0 0 0 0 0 0 1 0 0 0 1 X 5616 0 1 48 1 0 0 0 0 0 0 X 16 0 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X BENESYS INC 9252089999 2610 CROW CANYON ROAD SUITE 200 SAN RAMON CA 94583 X GARY SCHWENK 4.00 X 0 0 0 GARLAND SELF JR 1.00 X 0 0 0 CHRIS ENFANTINO 1.00 X 0 0 0 BOB BRAMLETT 1.00 X 0 0 0 BRUCE WORD 6.50 X 0 0 0 MITCHELL HOPPE 1.00 X 0 0 0 TIM O'CONNELL 2.00 X 0 0 0 JOSEPH A MARACCINI 5.00 X 0 0 0 PAUL STECKEL 3.00 X 0 0 0 PAUL ARSENAULT 2.00 X 0 0 0 RICHARD WERNER 2.00 X 0 0 0 WILLIE SOLIS 2.00 X 0 0 0 ROB STOKER 2.00 X 0 0 0 WILLIAM J LEFFLER JR 2.00 X 0 0 0 MIKE PENCE 2.00 X 0 0 0 BRETT RISLEY 2.00 X 0 0 0 0 0 0 0 0 0 0 BENESYS INC 2610 CROW CANYON ROAD SUITE 200 SAN RAMON CA 94583 ADMINISTRATION 2296396 BLUE CROSS 11050 OLSON DRIVE SUITE 110 RANCHO CORDOVA CA 94583 ADMINISTRATION 432817 PREMIER HEALTHCARE EXCHANGE INC 2 CROSSROADS DRIVE BEDMINSTER NJ 07921 ADMINISTRATION 193411 KAUFMAN & GOBLE 10 ALMADEN BOULEVARD SUITE 540 SAN JOSE CA 95113 CONSULTING 142500 FIRST HEALTH GROUP CORP 23284 NETWORK PLACE CHICAGO IL 60673 ADMINISTRATION 141450 6 EMPLOYER CONTRIBUTIONS 900099 66824555 66824555 EMPLOYEE CONTRIBUTIONS 900099 10269453 10269453 MEDICARE - D REBATES 900099 667710 667710 77761718 1257144 1257144 15507568 15516651 -9083 -9083 -9083 SETTLEMENT INCOME 900099 271055 271055 271055 79280834 78032773 0 1248061 67446448 2100864 95540 41220 85933 1710050 219755 3351 28834 OTHER EXPENSES 46554 71778549 -1182217 -616204 6809693 9759314 14965227 15245169 50620 50266 31645586 32586759 0 0 52288909 57025304 392388 365761 818406 823390 475181 296936 25722697 22779829 27408672 24265916 X 0 0 0 0 24880237 32759388 24880237 32759388 52288909 57025304 X 7502285 376866 X X 0 1 1 X 0 0 ACCUMULATED ELIGIBILTY CREDITS 17341000 INCURRED BUT NOT REPORTED CLAIMS 5353000 DUE TO BROKER 85829 22779829 79280834 71778549 7502285 376866 -397000 -20134 7482151 79571767 376866 376866 79194901 85933 85933 79280834 72089616 0 72089616 85933 -397000 -311067 71778549 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE PLAN'S ADMINISTRATOR HAS ANALYZED THE TAX POSITIONS TAKEN BY THE PLAN AND HAS CONCLUDED THAT AS OF JUNE 30, 2012 THERE ARE NO UNCERTAIN POSITIONS TAKEN, OR EXPECTED TO BE TAKEN, THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY THE TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE PLAN'S ADMINISTRATOR BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR THE YEARS PRIOR TO THE FISCAL YEAR ENDING JUNE 30, 2009. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN BENEFIT OBLIGATIONS -397,000. PART XIII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN BENEFIT OBLIGATIONS FORM 990, PART V, LINE 2A: THE PLAN DOES NOT HAVE ANY EMPLOYEES; HOWEVER, CERTAIN PARTICIPANTS OF THE PLAN RECEIVED A FORM W-2 FOR TAXABLE DOMESTIC PARTNER BENEFITS. FORM 990, PART VI, SECTION A, LINE 3 THE PLAN HAS CONTRACTED WITH BENESYS, INC TO PROVIDE ADMINISTRATIVE SERVICES FOR THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 WAS PROVIDED TO THE BOARD OF TRUSTEES FOR REVIEW BEFORE IT WAS FILED. FORM 990, PART VI, SECTION B, LINE 12C TRUSTEES ARE REQUIRED TO DISCLOSE IN WRITING ANY RELATIONSHIPS OR INTEREST THAT COULD GIVE RISE TO A CONFLICT. IF THERE IS A CONFLICT OF INTEREST, THE CONFLICTING INTEREST IS FULLY DISCLOSED AND DOCUMENTED IN WRITING; THE TRUSTEE OR FIDUCIARY WITH THE CONFLICT OF INTEREST IS EXCLUDED FROM THE DISCUSSION AND APPROVAL OF SUCH TRANSACTION. FORM 990, PART VI, SECTION C, LINE 19 UPON REQUEST, THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL INFORMATION AVAILABLE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 376,866. FORM 990, PART XII LINE 2C: THE ORGANIZATION HAS A BOARD OF TRUSTEES THAT ASSUMES RESPONSIBLITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED. LOCAL 104 SUPPLEMENTAL PENSION PLAN 2610 CROW CANYON ROAD SUITE 200 SAN RAMON CA 94583 946560138 THE PLAN PROVIDES SUPPLEMENTAL PENSION BENEFITS CA 501A N/A N/A 0 SHEET METAL WORKERS PENSION TRUST OF NORTHERN CALIFORNIA 2610 CROW CANYON ROAD SUITE 200 SAN RAMON CA 94583 516115939 THE PLAN PROVIDES PENSION BENEFITS TO RETIREES CA 501A N/A N/A 0 SHEET METAL WORKERS INTERNATIONAL ASSN LOCAL UNION NO 104 2610 CROW CANYON ROAD SUITE 300 SAN RAMON CA 94583 940859420 UNION CA 501C(5) N/A N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCHEDULE R, IDENTIFICATION OF RELATED ORGANIZATIONS: THE FILING ORGANIZATION IS A TAFT-HARTLEY MULTIEMPLOYER TRUST THAT PROVIDES HEALTH AND WELFARE BENEFITS TO ELIGIBLE EMPLOYEES AND THEIR DEPENDENTS. AS OF 6/30/12 THERE ARE APPROXIMATELY 338 EMPLOYERS THAT CONTRIBUTE TO THE TRUST. THE ADMINISTRATIVE OFFICE MAINTAINS A DATABASE OF THESE CONTRIBUTING EMPLOYERS, INCLUDING NAMES, ADDRESSES AND OTHER CONTACT INFORMATION. HOWEVER, CERTAIN INFORMATION THAT IS REQUIRED TO BE REPORTED ON SCHEDULE R, SUCH AS EMPLOYER IDENTIFICATION NUMBERS AND LEGAL STRUCTURE (CORPORATION, PARTNERSHIP, ETC.) FOR EACH CONTRIBUTING EMPLOYER, IS NOT ON FILE WITH THE ADMINISTRATIVE OFFICE AND IT COULD NOT BE REASONABLY OBTAINED. AS A RESULT, THE CONTRIBUTING EMPLOYERS HAVE NOT BEEN INCLUDED ON SCHEDULE R.