2012-11-15T09:02:29-06:00 2011-12-31 391531945 FREYBERG HINKLE ASHLAND POWERS & STOWELL 15420 W CAPITOL DR BROOKFIELD WI 530052621 990 2011-01-01 316041107 UFCW BENEFIT PLAN OF SOUTHWESTERN OHIO AREA UFCW 9376651900 7250 POE AVENUE NO 300 DAYTON OH 45414 STEVE LOEFFLER 9376651900 2012-11-15 1 THOMAS M POWERS CPA P00241729 2627846210 2011 2016-02-24 21:20:13Z STEVE LOEFFLER 7250 POE AVENUE NO 300 DAYTON OH 45414 110909113 0 X WWW.UFCWBENEFITPLAN.COM X EMPLOYEE BENEFIT PLAN 1957 OH THE PLAN PROVIDES MEDICAL, DENTAL, AND LIFE BENEFITS TO ITS MEMBERS AND DEPENDENTS. 8 8 21 0 0 0 0 0 66595889 98859173 1206671 493280 0 568378 67802560 99920831 0 0 58635317 90744560 990273 1224599 0 0 0 5143450 6773453 64769040 98742612 3033520 1178219 44120177 54186420 5625422 5142308 38494755 49044112 TO PROVIDE FOR A UNIFORM HEALTH AND WELFARE PROGRAM FOR EMPLOYEES EMPLOYED UNDER CERTAIN COLLECTIVE BARGAINING AGREEMENTS. 0 0 95232950 THE PLAN PROVIDES ACCIDENT, HEALTH, VISION, PRESCRIPTION, DENTAL, AND LIFE BENEFITS TO ITS MEMBERS AND DEPENDENTS. 95232950 0 0 0 0 0 0 0 0 0 1 1 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 1 568 0 1 21 1 0 0 0 0 0 0 X 8 8 0 0 0 0 0 0 0 1 1 0 0 0 1 0 1 1 1 1 0 0 X JERRY EVANS 9376651900 7250 POE AVENUE SUITE 300 DAYTON OH 45414 X LENNIE WYATT 1.00 X X 0 0 0 MERRITT HENDERSON 1.00 X 0 0 0 STEVE CULTER 1.00 X 0 0 0 TED SCHAEFER 1.00 X 0 0 0 STEVE LOEFFLER 1.00 X X 0 0 0 STEVE HENDRICKSON 1.00 X 0 0 0 KATHERINE LEV 1.00 X 0 0 0 JOE CHORPENNING 1.00 X 0 0 0 0 0 0 0 0 0 0 ANTHEM INSURANCE COMPANY INC PO BOX 182361 COLUMBUS OH 432182361 CLAIMS PROCESSING 2953704 THE SEGAL COMPANY 101 NORTH WACKER DRIVE STE 500 CHICAGO IL 60606 ACTUARY 569692 HEALTH SERVICE REVIEW INC 6730 ROOSEVELT FRANKLIN OH 45005 MEDICAL CASE MANAGEMENT 460120 REINHART BOERNER VAN DEUREN SC PO BOX 2965 MILWAUKEE WI 532012965 ATTORNEY 363939 APS HEALTHCARE BETHESDA INC 44 S BROADWAY 12TH FLOOR WHITE PLAINS NY 10601 DISEASE MANAGEMENT 341933 11 EMPLOYER CONTRIBUTIONS 900099 96834041 96834041 SELF-PAYMENT CONTRIB. 900099 2024814 2024814 LIQUIDATED DAMAGES 900099 318 318 98859173 504530 504530 10977032 10988282 -11250 -11250 -11250 GOVERNMENT REIMBURSEME 900099 568378 568378 568378 99920831 99427551 0 493280 90744560 90744560 838085 838085 50738 50738 265954 265954 69822 69822 142547 142547 374332 374332 84415 84415 28529 28529 589778 589778 518202 518202 252814 252814 95918 95918 51830 51830 22480 22480 64671 64671 PPO FEES AND MEDICAL RE 4344428 4344428 VISION SERVICE PLAN PRO 116085 116085 ONLINE OPEN ENROLLMENT 55347 55347 UCR SERVICES 24232 24232 7845 3645 4200 98742612 95232950 3509662 0 1184277 5015141 19672828 21510699 1468692 2343959 2312 33997 447439 384724 56534 62715 8719828 10260228 13015706 14959681 44120177 54186420 1972689 2851379 3251 11629 3649482 2279300 5625422 5142308 X 0 0 0 0 38494755 49044112 38494755 49044112 44120177 54186420 X 1178219 9371138 X X 0 1 1 X 0 447439 384724 62715 62715 COMMON AND COLLECTIVE FUNDS 14959681 F 14959681 CLAIMS PAYABLE 2279300 2279300 99920831 98742612 1178219 1030429 8340709 9371138 10549357 100922731 1030429 1030429 99892302 28529 28529 99920831 97819683 0 97819683 28529 894400 922929 98742612 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: U.S. GENERALLY ACCEPTED ACCOUNTING PRINCIPLES REQUIRE PLAN MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE PLAN AND RECOGNIZE A TAX LIABILITY (OR ASSET) IF THE PLAN HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS. THE PLAN ADMINISTRATOR HAS ANALYZED THE TAX POSITIONS TAKEN BY THE PLAN, AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2011, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY (OR ASSET) OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE PLAN ADMINISTRATOR BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO 2008. PART XI, LINE 8 - OTHER ADJUSTMENTS: TRANSFER OF NET ASSETS FROM UFCW LOCAL 911 H&W FUND 8,340,709. PART XIII, LINE 4B - OTHER ADJUSTMENTS: INCREASE IN CURRENT YEAR CLAIMS PAYABLE 894,400. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 GOES THROUGH A PRELIMINARY REVIEW BY THE ADMINISTRATIVE MANAGER AND ACCOUNTANT. ONCE THEY APPROVE THE FORM 990 IT IS PRESENTED TO A COMMITTEE OF TRUSTEES FOR APPROVAL PRIOR TO SIGNING AND FILING. FORM 990, PART VI, SECTION B, LINE 12C TRUSTEES ARE EXPECTED TO FULLY DISCLOSE ANY OWNERSHIP OR OTHER FINANCIAL RELATIONSHIPS THEY HAVE WITH OTHER PARTIES THAT DEAL WITH THE PLAN. FORM 990, PART VI, SECTION B, LINE 15A THE ADMINISTRATIVE MANAGER'S PAY RANGE IS DETERMINED BY THE BOARD OF TRUSTEES. THE TRUSTEES HAD A SALARY STUDY PERFORMED BY THE PLAN'S CONSULTANTS. THE TRUSTEES APPROVE INCREASES IN COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 THE PLAN MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 1,030,429. TRANSFER OF NET ASSETS FROM UFCW LOCAL 911 H&W FUND 8,340,709. TOTAL TO FORM 990, PART XI, LINE 5: 9,371,138. FORM 990, PART XII, LINE 2C THE BOARD OF TRUSTEES IS RESPONSIBLE FOR THE SELECTION OF AN INDEPENDENT ACCOUNTANT TO PERFORM THE AUDIT OF THE PLAN'S FINANCIAL STATEMENTS. FORM 990, SCHEDULE D, PART XI, LINE 10: THE $10,549,357 REPORTED HERE DOES NOT AGREE WITH THE NET INCREASE IN NET ASSETS AVAILABLE FOR BENEFITS AND THE TRANSFER OF NET ASSETS PER THE AUDITED FINANCIAL STATEMENTS AMOUNT OF $11,443,757. THE DIFFERENCE OF $894,400 IS THE CHANGE IN BENEFITS PAYABLE. THE BENEFITS PAYABLE ARE INCLUDED IN THE FORM 990, BUT ARE ONLY DISCLOSED IN THE NOTES TO THE AUDITED FINANCIAL STATEMENTS. FORM 990, SCHEDULE R, PARTS II-IV: ALL EMPLOYER INFORMATION IS AVAILABLE AT THE PLAN OFFICE UPON REQUEST. UNITED FOOD AND COMMERCIAL WORKERS UNION LOCAL NO 75 7250 POE AVENUE DAYTON OH 45414 310621221 LABOR UNION OH 501(C)(5) N/A 0 BOARD OF TRUSTEES OF THE UFCW BENEFIT PLAN OF SOUTHWESTERN OHIO AREA 7250 POE AVENUE DAYTON OH 45414 316173363 PLAN SPONSOR AND PLAN ADMINISTRATOR OH 501(C)(9) N/A 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 UNITED FOOD AND COMMERCIAL WORKERS UNION LOCAL NO 75 J 95918 FAIR MARKET VALUE UNITED FOOD AND COMMERCIAL WORKERS UNION LOCAL NO 75 O 131711 ACTUAL EXPENSE REIMBURSEMENTS