2024-04-05T10:41:55-05:00 2023-05-31 750786316 WEAVER AND TIDWELL LLP ONE PENNSYLVANIA PLAZA SUITE 3200 NEW YORK NY 10119 990 2022-06-01 111637886 LOCAL 804 WELFARE TRUST FUND LOCA 7187865410 44 S BAYLES AVENUE SUITE 302 PORT WASHINGTON NY 110503765 VINCENT PERRONE TRUSTEE 7187865410 2024-03-30 1 VINCENT PERRONE 999009999 0 XIAOMU DENG P01718982 2126955003 2024-03-29 3 AAL1 IAL1 2022 2023-04-26 12:10:37Z VINCENT PERRONE 44 S BAYLES AVENUE SUITE 302 PORT WASHINGTON NY 110503765 172103502 0 X HTTP://WWW.LOCAL804FUND.COM X 1950 NY TO PROVIDE HEALTH CARE BENEFITS 8 4 23 0 0 0 0 0 129167513 134663676 2932472 1660691 147358 256517 132247343 136580884 0 0 115650464 123379853 2501875 2638936 0 0 0 2025238 2298293 120177577 128317082 12069766 8263802 153577922 154905188 5831716 1775280 147746206 153129908 X THE LOCAL 804 WELFARE TRUST FUND WAS CREATED IN 1950, UNDER AN AGREEMENT AND DECLARATION OF TRUST, AS AMENDED, BETWEEN DELIVERY AND WAREHOUSE EMPLOYEES UNION, LOCAL 804 IBT (THE UNION") AND VARIOUS EMPLOYERS. THE UNION AND THE EMPLOYERS HAVE ENTERED INTO COLLECTIVE BARGAINING AGREEMENTS REQUIRING PAYMENTS BY THE EMPLOYERS FOR THE PURPOSE OF ESTABLISHING A WELFARE PROGRAM FOR THE EMPLOYERS TO PROVIDE WELFARE BENEFITS FOR THEIR EMPLOYEES AND THE EMPLOYEES OF THE UNION, AND THE EMPLOYEES OF THE LOCAL 804 WELFARE TRUST FUND. 0 0 PROVIDED HEALTH CARE BENEFITS FOR ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS. ESTIMATED NUMBER OF PARTICIPANTS BENEFITED DURING THE PAST YEAR WAS 5984. 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 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1 978 0 1 23 1 0 0 0 0 0 0 0 0 X 8 4 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 1 1 0 X MARC PANTELEONE FUND MANAGER 7187865410 44 S BAYLES AVENUE SUITE 302 PORT WASHINGTON NY 110503765 CHRIS LANGAN EMPLOYER TRUSTEE 1.00 X 0 0 0 MARK MCELREATH EMPLOYER TRUSTEE 1.00 X 0 0 0 MATTHEW LOUGHLIN EMPLOYER TRUSTEE 1.00 X 0 0 0 MICHAEL CLAYTON EMPLOYER TRUSTEE 1.00 X 0 0 0 VINCENT PERRONE UNION TRUSTEE 1.00 40.00 X 0 142823 57452 ANTONINO ROSCIGLIONE UNION TRUSTEE 1.00 40.00 X 0 142523 57452 CHRISTOPHER WILLIAMSON UNION TRUSTEE 1.00 40.00 X 0 143223 57452 ANTHONY CERULLI UNION TRUSTEE 1.00 40.00 X 0 143123 57452 MARC PANTELEONE FUND MANAGER 27.00 8.00 X 216720 0 59752 JAMES PANTELEONE IT AND BENEFIT CLAIMS ASSI 54.00 1.00 X 138823 0 32817 MAGGIE WU ACCOUNTANT 34.00 19.00 X 193088 0 33054 CELIA LIAW BENEFIT CLAIMS ASSISTANT 45.00 1.00 X 118193 0 32841 CHRISTINE NICOLETTI OFFICE MANAGER 35.00 1.00 X 112860 0 59752 JAMES SOLIWODA ADMIN CLERK 43.00 1.00 X 112712 0 32845 892396 571692 480869 6 0 1 0 EMPIRE HEALTHCHOICE ASSURANCE INC 165 BROADWAY NEW YORK NY 10006 BENEFIT ADMINISTRATIVE SERVICE 2211850 HEALTH PLAN SYSTEM 2025 LINCOLN HIGHWAY ROUTE 21 EDISON NJ 08817 BENEFIT INFORMATION TECHNOLOGY 484656 THE SEGAL COMPANY (EASTERN STATES) INC 333 WEST 34TH STREET NEW YORK NY 10001 ACTUARIAL AND CONSULTING SERVICES 478144 NEW YORK MEDICAL MANAGEMENT 2025 LINCOLN HIGHWAY ROUTE 21 EDISON NJ 08817 BENEFIT CONSULTING SERVICES 421665 PROSKAUER ROSE LLP ELEVEN TIMES SQUARE NEW YORK NY 10036 LEGAL SERVICES 370769 5 CONTRIBUTIONS - EMPLOYERS 900099 131614798 131614798 CONTRIBUTIONS - RETIRED PARTICIPA 900099 2845403 2845403 CONTRIBUTIONS - COBRA PARTICIPANT 900099 203475 203475 134663676 4056606 4056606 33126703 35522618 -2395915 -2395915 -2395915 MISCELLANEOUS INCOME 900099 256517 256517 256517 136580884 134920193 0 1660691 123379853 280252 1681119 54521 474009 149035 436555 49000 207202 554403 379031 621828 107262 27593 87272 72430 ADM.EXPENSES REIMBURSED -244980 697 128317082 2525890 947100 20377728 10937378 12761328 13187867 72944 106058 3828154 3498350 201544 329804 86471910 96842674 31166578 31577067 0 977240 153577922 154905188 435181 25864 269998 331824 5126537 1417592 5831716 1775280 X 0 0 0 0 147746206 153129908 147746206 153129908 153577922 154905188 8263802 -2880100 0 X 0 1 X 0 0 343540 337117 6423 1076716 834460 242256 2407898 2326773 81125 329804 COMMON COLLECTIVE TRUST 12539072 F LIMITED PARTNERSHIP 14877617 F ETF 4160378 F 31577067 DUE TO BROKER 433413 DUE TO LOCAL 804 PENSION FUND 4417 LEASE LIABILITY - OPERATING LEASE 979762 1417592 X 133493582 -2880100 -2880100 136373682 207202 207202 136580884 128109880 0 128109880 207202 207202 128317082 PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA 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 INTERNAL REVENUE SERVICE. THE PLAN ADMINISTRATOR HAS ANALYZED THE TAX POSITIONS TAKEN BY THE PLAN, AND HAS CONCLUDED THAT AS OF MAY 31, 2023, 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. EMPLOYEE BENEFIT PLANS ARE SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS FOR THE PLAN. THE PLAN ADMINISTRATOR BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO MAY 31, 2020. 0 0 0 MARC PANTELEONE FUND MANAGER 216720 0 0 0 0 0 33847 0 25905 0 276472 0 0 0 MAGGIE WU ACCOUNTANT 193088 0 0 0 0 0 6364 0 26690 0 226142 0 0 0 CHRISTOPHER WILLIAMSON UNION TRUSTEE 0 143223 0 0 0 0 0 31547 0 25905 0 200675 0 0 ANTHONY CERULLI UNION TRUSTEE 0 143123 0 0 0 0 0 31547 0 25905 0 200575 0 0 VINCENT PERRONE UNION TRUSTEE 0 142823 0 0 0 0 0 31547 0 25905 0 200275 0 0 ANTONINO ROSCIGLIONE UNION TRUSTEE 0 142523 0 0 0 0 0 31547 0 25905 0 199975 0 0 CHRISTINE NICOLETTI OFFICE MANAGER 112860 0 0 0 0 0 33847 0 25905 0 172612 0 0 0 JAMES PANTELEONE IT AND BENEFIT CLAIMS ASSI 138823 0 0 0 0 0 6364 0 26453 0 171640 0 0 0 CELIA LIAW BENEFIT CLAIMS ASSISTANT 118193 0 0 0 0 0 6364 0 26477 0 151034 0 0 0 FORM 990, PART VI, SECTION A, LINE 8B THE FUND DOES NOT HAVE ANY COMMITTEE WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE FUND'S BOARD OF TRUSTEES REVIEWS THE FORM 990 PRIOR TO ITS FILING. FORM 990, PART VI, SECTION B, LINE 15 THE FUND'S BOARD OF TRUSTEES REVIEWS AND AUTHORIZES COMPENSATION FOR ALL EMPLOYEES, INCLUDING FOR THE TOP MANAGEMENT OFFICIAL. THE REVIEW PROCESS IS CONDUCTED AT THE BOARD MEETING AND DOCUMENTED ACCORDINGLY. FORM 990, PART VI, SECTION C, LINE 19 THE FUND MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON RECEIPT OF A PARTICIPANT'S WRITTEN REQUEST. LOCAL 804 ANNUITY FUND 44 S BAYLES AVE PORT WASHINGTON NY 110503765 112506358 SHARED ADMINISTRATIVE COST NY 1.401-1(B)(3) 0 LOCAL 804 IBT 44 S BAYLES AVE PORT WASHINGTON NY 110503765 111603598 CONTRIBUTING EMPLOYER & RENTAL EXPENSE NY 501(C)(5) 0 LOCAL 804 PENSION FUND 44 S BAYLES AVE PORT WASHINGTON NY 110503765 116077200 SHARED ADMINISTRATIVE COST NY 1.401-1(B)(3) 0 LOCAL 804 FEDERAL CREDIT UNION 44 S BAYLES AVE PORT WASHINGTON NY 110503765 112491081 RELATED TO LOCAL 804 IBT, THE UNION NY 501(C)(1) 0 UNITED PARCEL SERVICE CONTRIBUTING EMPLOYER 0 TRUMP VILLAGE INC CONTRIBUTING EMPLOYER 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 1 0 0 LOCAL 804 ANNUITY FUND O 160023 SHARED ADM. COST AGREEMENT LOCAL 804 ANNUITY FUND N 36808 SHARED ADM. COST AGREEMENT LOCAL 804 IBT K 71052 OFFICE RENTAL EXPENSE LOCAL 804 PENSION FUND O 41936 SHARED ADM. COST AGREEMENT LOCAL 804 PENSION FUND N 6213 SHARED ADM. COST AGREEMENT LOCAL 804 PENSION FUND Q 36728 SHARED ADM. COST AGREEMENT LOCAL 804 ANNUITY FUND Q 135245 SHARED ADM. COST AGREEMENT BOYD WATTERSON STATE GOVERNMENT FUND LP ONE NORTH WACKER DRIVE SUITE 4025 CHICAGO IL 60606 320538379 INVESTMENT IL 483009 0 13703415 0 0 0.00730