2012-04-02T10:47:39-05:00 2011-05-31 BAUMAN ASSOCIATES LTD PO BOX 1225 EAU CLAIRE WI 547021225 990 2010-06-01 396095127 FOX VALLEY SHEET METAL HEALTH FUND C/O BENEFIT PLAN ADMINISTRATION FOXV 4145773700 2201 SPRINGDALE ROAD WAUKESHA WI 53186 PRESIDENT 4145773700 2012-04-02 GREGORY D MLEZIVA CPA 7158342001 2010 2016-02-24 21:20:13Z X NICHOLAS LIESCH 2201 SPRINGDALE ROAD WAUKESHA WI 53186 7889160 0 X N/A X 1981 WI TO PROVIDE WELFARE BENEFITS SUCH AS LIFE INSURANCE, ACCIDENTAL DEATH AND DISMEMBERMENT, LOSS OF TIME, DISABILITY, DENTAL, VISION, HOSPITAL, AND SURGICAL BENEFITS FOR UNION MEMBERS AND THEIR SPOUSES AND/OR DEPENDENTS. 6 6 0 0 0 0 0 0 6631415 7557310 331534 331850 0 0 6962949 7889160 0 0 7272222 5984780 0 0 0 0 0 460230 798920 7732452 6783700 -769503 1105460 9665846 10946522 2865200 2770891 6800646 8175631 TO PROVIDE WELFARE BENEFITS, SUCH AS LIFE INSURANCE, ACCIDENTAL DEATH AND DISMEMBERMENT, LOSS OF TIME, DISABILITY, DENTAL, VISION, HOSPITAL, AND SURGICAL BENEFITS FOR UNION MEMBERS AND THEIR SPOUSES AND/OR DEPENDENTS. 0 0 THE WELFARE FUND IS A NON-CONTRIBUTORY PLAN COVERING ALL MEMBERS OF THE FOX VALLEY SHEET METAL LOCAL #18. THE PLAN PROVIDES WELFARE BENEFITS SUCH AS LIFE INSURANCE, ACCIDENTAL DEATH OR DISMEMBERMENT, LOSS OF TIME, DISABILITY, DENTAL, VISION, HOSPITAL, AND SURGICAL BENEFITS. 0 0 0 0 0 0 0 0 0 0 0 1 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 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 X 6 6 0 0 0 0 0 0 0 1 1 1 0 0 1 1 1 1 1 0 0 0 X BENEFIT PLAN ADMINISTRATION 4145773700 2201 SPRINGDALE ROAD WAUKESHA WI 53186 X NICHOLAS LIESCH 1.00 X X 0 0 0 CHARLES SCHUSTER 1.00 X X 0 0 0 PATRICK LANDGRAF 1.00 X 0 0 0 PAUL HANSEN 1.00 X 0 0 0 TOM FELDMANN 1.00 X 0 0 0 JEFFREY GAECKE 1.00 X 0 0 0 0 0 0 0 0 0 0 RELIASTAR LIFE INSUARNCE COMPANY 3702 PAYSPHERE CIRCLE CHICAGO IL 60674 STOP-LOSS, LIFE, AND ACCIDENTAL DEATH 564640 BENEFIT PLAN ADMINISTRATION OF WI INC 11270 W PARK PLACE SUITE 950 MILWAUKEE WI 53224 THIRD PARTY ADMINISTRATOR 224143 UNITED HEALTH CARE INSURANCE COMPANY 10701 W RESEARCH DRIVE MILWAUKEE WI 53226 CLAIMS PROCESSING 135415 3 EMPLOYER CONTRIBUTIONS 900099 6484150 6484150 PARTICIPANT CONTRIBUTI 900099 548553 548553 SUBROGATION 900099 379585 379585 STOP-LOSS REIMBURSEMEN 900099 107288 107288 SUBSIDY REIMBURSEMENTS 900099 34865 34865 2869 2869 7557310 331850 331850 7889160 7557310 0 331850 5984780 60724 27484 358121 5954 PPO SERVICE ADMINISTRAT 169779 MISCELLANEOUS EXPENSES 81262 PAYMENTS TO LOCALS 65470 BANK FEES 25562 FICA PAID ON DISABILITY 4564 6783700 1548978 2318030 59389 67329 7419777 7896140 637702 665023 9665846 10946522 77200 80291 2788000 2690600 2865200 2770891 X 0 0 0 0 6800646 8175631 6800646 8175631 9665846 10946522 X 1105460 269525 X X 0 1 1 X 0 0 CONTRIBUTIONS RECEIVABLE 519231 STOP-LOSS RECEIVABLE 93338 OTHER RECEIVABLES 52454 665023 ESTIMATED LIABILITY FOR FUTURE BENEFITS 2335000 HEALTH CLAIMS PAYABLE AND CLAIMS IBNR 355600 2690600 7889160 6783700 1105460 172125 97400 269525 1374985 8061285 172125 172125 7889160 0 7889160 6783700 0 6783700 0 6783700 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE FUND HAS ADOPTED FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ASC 740, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES. THE FUND WILL RECOGNIZE ANY ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED BENEFITS IN INCOME TAX, IF INCURRED. THE FUND'S PREVIOUS 3 TAX YEARS ARE OPEN FOR EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN ESTIMATED LIABILITY FOR FUTURE BENEFITS -3,000. (INCREASE) DECREASE IN IBNR 100,400. FORM 990, PART VI, SECTION B, LINE 11 THE FUND'S ATTORNEY REVIEWS FORM 990 BEFORE IT IS FILED. THE CHAIRMAN OF THE BOARD OF TRUSTEES SIGNS FORM 990 ONCE IT HAS BEEN REVIEWED BY THE ATTORNEY. FORM 990, PART VI, SECTION B, LINE 12C THE TRUSTEES ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST IMMEDIATELY UPON DISCOVERY. EACH TRUSTEE HAS SIGNED AN AGREEMENT STATING THAT HE WILL ACT IN ACCORDANCE WITH THE TRUST AGREEMENT. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTATION IS AVAILABLE UPON REQUEST BY CONTACTING THE FUND OR THE FUND'S ADMINISTRATOR. CONTACT ADDRESSES FOR OFFICERS, DIRECTORS, ETC FORM 990, PART VII NICHOLAS LIESCH - 2901 WELHOUSE DRIVE, KAUKAUNA, WI 54130-3541. CHARLES SCHUSTER - 51 WEST FERNAU AVENUE, OSHKOSH, WI 54901. PATRICK LANDGRAF - 2201 SPRINGDALE ROAD, WAUKESHA, WI 53186. PAUL HANSEN - 625 SAINT MARY'S STREET, DE PERE, WI 54115-1069. TOM FELDMANN - P.O. BOX 492, APPLETON, WI 54912-0492. JEFFREY GAECKE - 3315 NORTH BALLARD ROAD, SUITE D, APPLETON, WI 54911-8988. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 172,125. CHANGE IN ESTIMATED LIABILITY FOR FUTURE BENEFITS -3,000. (INCREASE) DECREASE IN IBNR 100,400. TOTAL TO FORM 990, PART XI, LINE 5: 269,525. FORM 990, PART XI, LINE 12C: NO CHANGES HAVE BEEN MADE SINCE PRIOR YEAR.