2022-04-01T10:07:46-05:00 2021-05-31 131578842 BUCHBINDER TUNICK & COMPANY LLP ONE PENNSYLVANIA PLAZA SUITE 3200 NEW YORK NY 10119 990 2020-06-01 111637886 LOCAL 804 WELFARE TRUST FUND LOCA 7187865410 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 VINCENT PERRONE TRUSTEE 7187865410 2022-03-26 1 VINCENT PERRONE 999009999 GREG AUTERI P01366109 2126955003 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z VINCENT PERRONE 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 167201363 0 X HTTP://WWW.LOCAL804FUND.COM X 1950 NY TO PROVIDE HEALTH CARE BENEFITS 8 4 23 0 0 0 0 0 107523865 119663197 2800986 6471449 110693 23456 110435544 126158102 0 0 89666073 96970497 2661146 2535632 0 0 0 4729050 1917760 97056269 101423889 13379275 24734213 124992884 147164982 3635017 957923 121357867 146207059 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 5678. 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 1 606 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 34-21 REVIEW AVENUE LONG ISLAND CITY NY 11101 CHRIS LANGAN EMPLOYER TRUSTEE 1.00 X 0 0 0 RYAN THIBODEAU 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 133741 52991 ANTONINO ROSCIGLIONE UNION TRUSTEE 1.00 40.00 X 0 133441 52991 CHRISTOPHER WILLIAMSON UNION TRUSTEE 1.00 40.00 X 0 133341 52991 ANTHONY CERULLI UNION TRUSTEE 1.00 40.00 X 0 133441 52991 MARC PANTELEONE FUND OFFICE MANAGER 28.00 7.00 X 204951 0 55155 JAMES PANTELEONE IT AND BENEFIT CLAIMS ASSI 54.00 1.00 X 144402 0 30712 MAGGIE WU ACCOUNTANT 43.00 10.00 X 185938 0 30936 CELIA LIAW BENEFIT CLAIMS ASSISTANT 43.00 1.00 X 100972 0 30735 636263 533964 359502 4 0 1 0 EMPIRE HEALTHCHOICE ASSURANCE INC 165 BROADWAY NEW YORK NY 10006 BENEFIT ADMINISTRATIVE SERVICE 2061026 PROSKAUER ROSE LLP ELEVEN TIMES SQUARE NEW YORK NY 10036 LEGAL SERVICES 572447 THE SEGAL COMPANY (EASTERN STATES) INC 333 WEST 34TH STREET NEW YORK NY 10001 ACTUARIAL AND CONSULTING SERVICES 437479 HEALTH PLAN SYSTEM 2025 LINCOLN HIGHWAY ROUTE 21 EDISON NJ 08817 BENEFIT INFORMATION TECHNOLOGY 389112 NEW YORK MEDICAL MANAGEMENT 2025 LINCOLN HIGHWAY ROUTE 21 EDISON NJ 08817 BENEFIT CONSULTING SERVICES 341691 5 CONTRIBUTIONS - EMPLOYERS 900099 116726586 116726586 CONTRIBUTIONS - RETIRED PARTICIPA 900099 2861177 2861177 CONTRIBUTIONS - COBRA PARTICIPANT 900099 75434 75434 119663197 2833269 2833269 44681441 41043261 3638180 3638180 3638180 MISCELLANEOUS INCOME 900099 23456 23456 23456 126158102 119686653 0 6471449 96970497 256622 1570072 133965 438485 136488 578828 49000 210670 445344 236062 387746 103806 1488 72856 42950 MISCELLANEOUS 302 ADM.EXPENSES REIMBURSED -211860 568 101423889 3149986 2783508 14624217 14671527 14491121 15026658 101635 56481 3604853 3337253 331057 267600 85442862 85715652 6852006 28643556 124992884 147164982 438351 111262 219234 262251 2977432 584410 3635017 957923 X 0 0 0 0 121357867 146207059 121357867 146207059 124992884 147164982 24734213 114979 0 X 0 1 X 0 0 339467 335862 3605 866238 777243 88995 2399148 2224148 175000 267600 COMMON COLLECTIVE TRUST 13240550 F LIMITED PARTNERSHIP 10899630 F ETF 4503376 F 28643556 EST'D FUTURE RETIREMENT BENEFIT 121280 DUE TO LOCAL 804 ANNUITY FUND 48314 DUE TO BROKER 414816 584410 X 126062411 114979 114979 125947432 210670 210670 126158102 101213219 0 101213219 210670 210670 101423889 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, 2021, 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, 2018. 0 0 0 MARC PANTELEONE FUND OFFICE MANAGER 204951 0 0 0 0 0 31087 0 24068 0 260106 0 0 0 MAGGIE WU ACCOUNTANT 185938 0 0 0 0 0 6128 0 24808 0 216874 0 0 0 VINCENT PERRONE UNION TRUSTEE 0 133741 0 0 0 0 0 28923 0 24068 0 186732 0 0 ANTONINO ROSCIGLIONE UNION TRUSTEE 0 133441 0 0 0 0 0 28923 0 24068 0 186432 0 0 ANTHONY CERULLI UNION TRUSTEE 0 133441 0 0 0 0 0 28923 0 24068 0 186432 0 0 CHRISTOPHER WILLIAMSON UNION TRUSTEE 0 133341 0 0 0 0 0 28923 0 24068 0 186332 0 0 JAMES PANTELEONE IT AND BENEFIT CLAIMS ASSI 144402 0 0 0 0 0 6128 0 24584 0 175114 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 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 112506358 SHARED ADMINISTRATIVE COST NY 1.401-1(B)(3) 0 LOCAL 804 IBT 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 111603598 CONTRIBUTING EMPLOYER & RENTAL EXPENSE NY 501(C)(5) 0 LOCAL 804 FEDERAL CREDIT UNION 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 112491081 CONTRIBUTING EMPLOYER NY 501(C)(1) 0 LOCAL 804 PENSION FUND 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 116077200 SHARED ADMINISTRATIVE COST NY 1.401-1(B)(3) 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 96244 SHARED ADM. COST AGREEMENT LOCAL 804 ANNUITY FUND N 68610 SHARED ADM. COST AGREEMENT LOCAL 804 IBT K 61560 OFFICE RENTAL EXPENSE LOCAL 804 PENSION FUND O 30183 SHARED ADM. COST AGREEMENT LOCAL 804 PENSION FUND N 16823 SHARED ADM. COST AGREEMENT LOCAL 804 PENSION FUND Q 69771 SHARED ADM. COST AGREEMENT LOCAL 804 ANNUITY FUND Q 265573 SHARED ADM. COST AGREEMENT BOYD WATTERSON STATE GOVERNMENT FUND LP ONE NORTH WACKER DRIVE SUITE 4025 CHICAGO IL 60606 320538379 INVESTMENT IL 50085 0 0 3039210 0 0 0 0.00460