2013-11-15T16:00:08-06:00 2012-12-31 510545975 PETER DECARLO CPA PLLC 112 WEST 34TH STREET 18TH FLOOR NEW YORK NY 10120 990 2012-01-01 160915820 UFCW LOCAL ONE HEALTH CARE FUND UFCW 3157979600 5911 AIRPORT ROAD ORISKANY NY 13424 FRANK C DERISO 3157979600 2013-11-15 1 PETER DECARLO CPA P00851470 2129464907 X 2012 2016-03-07 17:11:31Z FRANK C DERISO 5911 AIRPORT ROAD ORISKANY NY 13424 74206987 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 64871237 66997823 1074821 979510 0 0 65946058 67977333 0 0 60231122 55712529 1198764 1217838 0 0 0 1248559 1219448 62678445 58149815 3267613 9827518 35061180 48387912 292138 1010400 34769042 47377512 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 13,050 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 1 160 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 1.00 X 0 252111 21913 ERIC A GLATHAR 1.00 X 0 198855 20484 GREGORY P GOREA 1.00 X 0 181648 20251 DONALD ELIASON 1.00 X 0 132786 18611 JOHN BARRETT 1.00 X 0 0 0 RAYMOND WARDYNSKI 1.00 X 0 0 0 I STEPHEN DAVIS 1.00 X 0 0 0 KRISTINE WYDRO 1.00 X 0 0 0 ANDREA GOLDBERGER 22.00 X 131864 0 29615 MICHAEL CIANCAGLINI 40.00 X 106212 0 27661 238076 765400 138535 2 0 1 0 SLEVIN & HART PC 1625 MASSACHUSETTS AVENUE NW WASHINGTON DC 20036 LEGAL 123489 1 EMPLOYER CONTRIBUTIONS 525100 64632342 64632342 PARTICIPANT CONTRIBUTIONS 525100 2358747 2358747 LIQUIDATED DAMAGES 525100 6734 6734 66997823 1017926 1017926 6191238 6229654 -38416 -38416 -38416 67977333 66997823 0 979510 55712529 839128 117772 191789 69149 139399 56000 83618 165967 96728 153128 24952 24445 17434 54437 COMPUTER EXPENSE 283644 OPERATIONS EXPENSE 52181 PRINTING & PUBLICATIONS 31721 AFFORDABLE CARE ACT PRE 18110 17684 58149815 18170 10145 4860949 10178912 4839650 6848751 25675 268010 2031505 2018801 25796 12704 24140334 29918784 1150606 1150606 35061180 48387912 203586 185624 88552 824776 292138 1010400 X 0 0 0 0 34769042 47377512 34769042 47377512 35061180 48387912 9827518 280836 2500116 0 X X 0 1 X 1 0 28682 28682 0 668985 659790 9195 1333838 1330329 3509 12704 DUE TO BROKER FOR SECURITIES PURCHASED 712191 DUE TO UFCW LOCAL ONE PENSION FUND 90587 DUE TO UFCW DISTRICT UNION LOCAL ONE 21998 824776 68174551 280836 280836 67893715 83618 83618 67977333 58066197 0 58066197 83618 83618 58149815 X 0 0 0 FRANK C DERISO 0 252111 0 0 0 0 0 9401 0 12512 0 274024 0 0 ERIC A GLATHAR 0 198855 0 0 0 0 0 7972 0 12512 0 219339 0 0 GREGORY P GOREA 0 181648 0 0 0 0 0 7740 0 12511 0 201899 0 0 DONALD ELIASON 0 132786 0 0 0 0 0 6332 0 12279 0 151397 0 0 ANDREA GOLDBERGER 131864 0 0 0 0 0 10451 0 19164 0 161479 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 0 ADIRONDACK MEDICAL CENTER 0 ST ELIZABETH MEDICAL CENTER 0 TOPS MARKETS INC 0 EMPIRE MERCHANTS NORTH ALBANY 0 KRAFT FOODS INC 0 GREAT AMERICAN STORES 0 HERITAGE HEALTH CARE CENTER 0 GRAND UNION FAMILY MARKETS 0 SILGAN CONTAINERS MANUFACTURING CORP 0 SAHLEN PACKING CORP 0 G&L DAVIS MEAT CO 0 HOMETOWN MARKETS LLC 0 THORNES OF WARREN 0 SPECIALTY STEAK 0 EMPIRE MERCHANTS NORTH BUFFALO 0 SHOP RITE SUPERMARKETS INC 0 CHANATRY'S FRENCH ROAD MARKET 0 ZWEIGLES INC 0 GIANT EAGLE INC 0 SODEXO INC 0 WELCH FOODS INC 0 CARRIER COACH 0 BREENS FAMILY INC 0 FORT'S GROCERY INC 0 SMITH PACKING COMPANY 0 WALTON'S BIG M 0 HOFMANN SAUSAGE CO INC 0 OLD WORLD PROVISION CO INC 0 LR BRASS INC 0 COUDERSPORT JUBILEE 0 SMYD CORP 0 DIVERSE FOOD PRODUCTS LLC 0 PROVIDENTIAL FOODS CORP 0 VANCHLOR CO 0 FRANK WARDYNSKI & SONS INC 0 PARKVIEW SUPERMARKET 0 SMITH PROVISION CO INC 0 PORT ALLEGANY JUBILEE 0 TN HARVEY INC 0 PAWLAKS FOOD CENTER 0 FILLMORE JUBILEE 0 GALETON IGA 0 INDELICATO'S MARKET 0 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 335825 ALLOCATION UFCW LOCAL ONE PENSION FUND Q 888918 ALLOCATION UFCW LOCAL ONE 401(K) SAVINGS PLAN Q 141749 ALLOCATION LUTHERAN HOMES S 1399629 CONTRACT ADIRONDACK MEDICAL CENTER S 1126791 CONTRACT ST ELIZABETH MEDICAL CENTER S 1055693 CONTRACT UFCW DISTRICT UNION LOCAL ONE S 467031 CONTRACT TOPS MARKETS INC S 44821528 CONTRACT EMPIRE MERCHANTS NORTH ALBANY S 1558075 CONTRACT KRAFT FOODS INC S 1259168 CONTRACT GREAT AMERICAN STORES S 948119 CONTRACT HERITAGE HEALTH CARE CENTER S 746264 CONTRACT GRAND UNION FAMILY MARKETS S 740269 CONTRACT SILGAN CONTAINERS MANUFACTURING CORP S 685807 CONTRACT SAHLEN PACKING CORP S 662628 CONTRACT G&L DAVIS MEAT CO S 615360 CONTRACT HOMETOWN MARKETS LLC S 584621 CONTRACT THORNES OF WARREN S 512754 CONTRACT SPECIALTY STEAK S 461836 CONTRACT EMPIRE MERCHANTS NORTH BUFFALO S 442327 CONTRACT SHOP RITE SUPERMARKETS INC S 388621 CONTRACT CHANATRY'S FRENCH ROAD MARKET S 313210 CONTRACT ZWEIGLES INC S 259381 CONTRACT GIANT EAGLE INC S 243219 CONTRACT SODEXO INC S 230593 CONTRACT WELCH FOODS INC S 227692 CONTRACT CARRIER COACH S 204868 CONTRACT BREENS FAMILY INC S 201537 CONTRACT FORT'S GROCERY INC S 195528 CONTRACT SMITH PACKING COMPANY S 185164 CONTRACT WALTON'S BIG M S 177675 CONTRACT HOFMANN SAUSAGE CO INC S 174692 CONTRACT OLD WORLD PROVISION CO INC S 157785 CONTRACT LR BRASS INC S 142470 CONTRACT COUDERSPORT JUBILEE S 142010 CONTRACT SMYD CORP S 132626 CONTRACT DIVERSE FOOD PRODUCTS LLC S 128322 CONTRACT PROVIDENTIAL FOODS CORP S 116045 CONTRACT VANCHLOR CO S 102852 CONTRACT FRANK WARDYNSKI & SONS INC S 93467 CONTRACT PARKVIEW SUPERMARKET S 92286 CONTRACT SMITH PROVISION CO INC S 88180 CONTRACT PORT ALLEGANY JUBILEE S 85556 CONTRACT TN HARVEY INC S 61734 CONTRACT PAWLAKS FOOD CENTER S 60610 CONTRACT FILLMORE JUBILEE S 57127 CONTRACT GALETON IGA S 56459 CONTRACT INDELICATO'S MARKET S 50016 CONTRACT