2024-08-06T14:52:10-05:00 2023-09-30 420714325 RSM US LLP 400 LOCUST ST STE 640 DES MOINES IA 503092372 990 2022-10-03 421170511 HY-VEE AND AFFILIATES' BENEFIT PLAN AND TRUST HY-V 5152672800 5820 WESTOWN PARKWAY WEST DES MOINES IA 50266 ANDREW SCHREINER TRUSTEE 5152672800 2024-08-06 1 1 TY P DOGGETT P00810916 5155586600 2024-08-06 2022 2024-08-08 14:25:15Z ANDREW SCHREINER 5820 WESTOWN PARKWAY WEST DES MOINES IA 50266 217149390 0 X N/A X 1981 IA IT IS THE MISSION OF THE HY-VEE AND AFFILIATES BENEFIT PLAN TO MAKE EMPLOYEE'S LIVES EASIER, HEALTHIER, AND HAPPIER BY PROVIDING FOR THE HEALTH AND RELATED BENEFIT NEEDS OF THE ADOPTING COMPANIES' EMPLOYEES AND THEIR DEPENDENTS. 3 0 0 3 74327 73327 0 0 205292272 216490887 72847 658503 0 0 205365119 217149390 0 0 198083407 193691573 0 0 0 0 0 12605756 12343792 210689163 206035365 -5324044 11114025 23465030 32189368 27202476 24343147 -3737446 7846221 TO PROVIDE QUALITY, COST-EFFECTIVE AND COMPREHENSIVE MEDICAL, DENTAL, LIFE AND DISABILITY BENEFITS; TO PROVIDE MEANINGFUL INFORMATION, RESOURCES, AND ASSISTANCE; AND TO PROVIDE PREVENTIVE AND WELLNESS-RELATED INTERVENTIONS AND PROGRAMS. 0 0 THIS TRUST IS ESTABLISHED TO PROVIDE FOR THE HEALTH AND RELATED BENEFIT NEEDS OF THE ADOPTING COMPANIES' EMPLOYEES AND THEIR DEPENDENTS. DURING THE YEAR ENDED OCTOBER 1, 2023, THE PLAN PROVIDED BENEFITS TO ABOUT 16,000 EMPLOYEES. 0 0 0 0 0 0 0 0 0 0 0 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 1 0 0 0 1 1 0 0 0 0 0 0 0 X 3 0 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X X ANDREW SCHREINER 5152672800 5820 WESTOWN PARKWAY WEST DES MOINES IA 50266 X KRISTINE JONES TRUSTEE 1.00 40.00 X 0 0 0 ANDREW SCHREINER TRUSTEE 1.00 40.00 X 0 0 0 GEORGIA VAN GUNDY TRUSTEE 1.00 40.00 X 0 0 0 0 0 0 0 0 0 0 WELLMARK INC 636 GRAND AVE DES MOINES IA 503092565 CONTRACT ADMINISTRATOR 9992607 VIVID CLEAR RX 13220 BIRCH DRIVE SUITE 200 OMAHA NE 68164 ADMINISTRATOR 769988 DELTA DENTAL 2401 SE TONES DR 13 ANKENY IA 500218665 ADMINISTRATOR 661891 LINCOLN FINANCIAL GROUP 1300 S CLINTON ST FORT WAYNE IN 46802 ADMINISTRATOR 383434 OUTCOMES INCORPORATED 505 MARKET STREET SUITE 200 WEST DES MOINES IA 50266 CONSULTING SERVICES 213453 7 EMPLOYER CONTRIBUTIONS 900099 166392480 166392480 EMPLOYEE CONTRIBUTIONS 900099 50098407 50098407 216490887 658503 74327 584176 217149390 216490887 74327 584176 193691573 11815441 527206 MISCELLANEOUS EXPENSES 2845 INCOME TAXES -1700 206035365 -2185 16491000 23743000 6776374 7674157 112671 772211 87170 23465030 32189368 4552464 2162777 22650012 22180370 27202476 24343147 X -3737446 7846221 0 0 0 0 -3737446 7846221 23465030 32189368 X 11114025 469642 X 0 1 X 0 0 0 BENEFIT OBLIGATIONS 22180370 22180370 X 217149390 0 217149390 0 217149390 206035365 0 206035365 0 206035365 PART X, LINE 2: THE TRUST ESTABLISHED UNDER THE PLAN TO HOLD THE PLAN'S NET ASSETS IS QUALIFIED PURSUANT TO SECTION 501(C)(9) OF THE INTERNAL REVENUE CODE AND, ACCORDINGLY, THE TRUST'S NET INVESTMENT INCOME IS EXEMPT FROM INCOME TAXES. THE SPONSOR HAS OBTAINED A FAVORABLE TAX DETERMINATION LETTER DATED MAY 18, 1982 FROM THE INTERNAL REVENUE SERVICE AND THE SPONSOR BELIEVES THAT THE TRUST, AS AMENDED, CONTINUES TO QUALIFY AND TO OPERATE AS DESIGNED. MANAGEMENT HAS EVALUATED THE PLAN'S TAX POSITIONS AND CONCLUDED THAT THE PLAN HAS MAINTAINED ITS TAX EXEMPT STATUS AND HAS TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENTS TO THE FINANCIAL STATEMENTS. HOWEVER, AS A RESULT OF THE PLAN'S FUNDING POLICY, FROM TIME TO TIME, THE TRUST MAY BE SUBJECT TO INCOME TAXES ON UNRELATED BUSINESS INCOME. NO FEDERAL OR STATE INCOME TAXES HAVE BEEN RECORDED IN 2023 OR 2022. GENERALLY, THE STATUTE OF LIMITATIONS FOR EXAMINATION OF U.S. FEDERAL OR STATE TAX RETURNS IS THREE YEARS AND IS CONSIDERED CLOSED UPON REVIEW BY THE TAXING JURISDICTION. FORM 990, PART VI, SECTION A, LINE 2 THE TRUSTEES HAVE A BUSINESS RELATIONSHIP AS THEY ARE EMPLOYED BY THE SAME COMPANY. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF THE FINAL FORM 990, AS FILED WITH THE IRS, IS PROVIDED TO THE TRUSTEES PRIOR TO FILING THE FORM. THE TRUSTEES ARE AVAILABLE FOR REVIEW PRIOR TO FILING THE FORM. FORM 990, PART VI, SECTION B, LINE 12C HY-VEE AND AFFILIATES' BENEFIT PLAN AND TRUST HAS A CONFLICT OF INTEREST POLICY. TRUSTEES ANNUALLY COMPLETE AND SIGN A CONFLICT OF INTEREST STATEMENT. TO THE EXTENT A TRUSTEE HAS A CONFLICT OF INTEREST, THEY LEAVE THE ROOM AND ABSTAIN FROM VOTING ON SUCH MATTER. IDENTIFIED CONFLICT OF INTEREST SITUATIONS AND DELIBERATIONS ARE CONTEMPORANEOUSLY DOCUMENTED IN THE MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST FOR VIEWING IN THE OFFICE OF THE PLAN ADMINISTRATOR. THE FORM 990 IS AVAILABLE ON GUIDESTAR.ORG. FORM 990, PART VII, SECTION A, LINE 1A(B): THE TRUSTEES ARE EMPLOYEES OF THE RELATED ORGANIZATION AND SERVE AS VOLUNTEER TRUSTEES FOR THE ORGANIZATION. FORM 990, PART XI, LINE 9: ADJUSTMENT TO BENEFIT OBLIGATIONS 469,642. FORM 990, A - TAX YEAR END: HY-VEE BENEFIT PLAN AND TRUST HAS A 52/53-WEEK TAX YEAR. THE TAX YEAR END IS THE CLOSEST SUNDAY TO 9/30. GIVEN THIS, THE TAX YEAR END FLUCTUATES BETWEEN THE MONTHS OF SEPTEMBER AND OCTOBER. THE IRS EXEMPT ORGANIZATION E-FILING SYSTEM ONLY ALLOWS A TAXPAYER'S YEAR END TO FALL ON THE SAME MONTH EACH YEAR, AS SUCH THE TAX RETURN IS UNABLE TO BE E-FILED USING THE CORRECT TAX YEAR END. BECAUSE FORMS 990 ARE MANDATED TO BE E-FILED, THIS RETURN HAS BEEN E-FILED USING A 9/30/23 YEAR END. THE ACTUAL TAX YEAR END FOR THE 2022 TAX YEAR IS 10/1/2023. HY-VEE INC 5820 WESTOWN PARKWAY WEST DES MOINES IA 50266 420325638 RETAIL SALES IA N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1