2012-04-06T15:40:09-05:00 2011-06-30 LINDQUIST LLP 5000 EXECUTIVE PARKWAY SUITE 400 SAN RAMON CA 945834210 990 2010-07-01 942541328 SHEET METAL WORKERS LOCAL 104 HEALTH CARE PLAN SHEE 9252089999 2610 CROW CANYON ROAD NO 200 SAN RAMON CA 94583 BRUCE WORD 9252089999 2012-04-06 1 9252779100 2010 2016-02-24 21:20:13Z BRUCE WORD 2610 CROW CANYON ROAD SUITE 200 SAN RAMON CA 94583 142929341 0 X N/A X 1979 CA TO PROVIDE HEALTH BENEFITS AND SUPPLEMENTAL UNEMPLOYMENT BENEFITS 16 16 64 0 0 0 0 0 62122845 71092788 2315437 4587094 182276 395676 64620558 76075558 0 0 73339707 70948834 0 0 0 0 0 3896897 3963998 77236604 74912832 -12616046 1162726 50844893 52288909 26768089 27408672 24076804 24880237 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 1 0 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 6000 0 1 64 1 0 0 0 0 0 0 X 16 16 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 2236186 BLUE CROSS 11050 OLSON DRIVE SUITE 110 RANCHO CORDOVA CA 94583 ADMINISTRATION 464979 KAUFMAN & GOBLE 10 ALMADEN BOULEVARD SUITE 540 SAN JOSE CA 95113 CONSULTING 126000 ENVISION 2181 E AURORA ROAD SUITE 201 TWINSBURG OH 44087 ADMINISTRATION 124556 GLOBAL CARE IN 6875 SHILOH RD EAST ALPHARETTA GA 30005 ADMINISTRATION 117709 6 EMPLOYER CONTRIBUTIONS 900099 58915754 58915754 EMPLOYEE CONTRIBUTIONS 900099 10558431 10558431 MEDICARE - D REBATES 900099 1097385 1097385 ERRP INCOME 900099 521218 521218 71092788 1404055 1404055 70036822 66853783 3183039 3183039 3183039 SETTLEMENT INCOME 900099 395676 395676 395676 76075558 71488464 0 4587094 70948834 2086048 68243 43035 102879 1352074 215267 12150 26504 OTHER EXPENSES 57798 74912832 -1275886 -1182217 5320483 6809693 10817591 14965227 54843 50620 35927862 31645586 50844893 52288909 369623 392388 771700 818406 661766 475181 24965000 25722697 26768089 27408672 X 0 0 0 0 24076804 24880237 24076804 24880237 50844893 52288909 X 1162726 -359293 X X 0 1 1 X 0 0 ACCUMULATED ELIGIBILTY CREDITS 16983000 INCURRED BUT NOT REPORTED CLAIMS 6108000 DUE TO BROKER 2631697 25722697 76075558 74912832 1162726 -359293 -1874000 -2233293 -1070567 75613386 -359293 -359293 75972679 102879 102879 76075558 76683953 0 76683953 102879 -1874000 -1771121 74912832 PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN BENEFIT OBLIGATIONS PART XIII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN BENEFIT OBLIGATIONS 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 LOSSES ON INVESTMENTS: -359,293. 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. 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. 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0