2022-07-15T11:26:42-05:00 2021-09-30 208149084 ANASTASI MOORE & MARTIN PLLC 9 S WASHINGTON ST STE 600 SPOKANE WA 99201 990 2020-10-01 810305103 MONTANA RETAIL STORE EMPLOYEES HEALTH & WELFARE TRUST MONT 5095345625 111 WEST CATALDO AVENUE NO 220 SPOKANE WA 99201 NICOLAI B COCERGINE PRESIDENT 5095345625 2022-07-07 1 NICOLAI COCERGINE 999009999 PAUL ANASTASI CPA P00395796 5093230272 2022-07-07 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z NICOLAI B COCERGINE 111 WEST CATALDO AVENUE NO 220 SPOKANE WA 99201 12488989 0 X N/A X 1968 MT TO PROVIDE HEALTH AND WELFARE BENEFITS FOR COVERED EMPLOYEES IN ACCORDANCE WITH THE PLAN. 6 0 0 7 0 0 0 0 11174683 12095639 100194 22839 305743 370511 11580620 12488989 0 0 11402673 10409702 0 0 0 0 0 1045530 1017495 12448203 11427197 -867583 1061792 13535709 13835872 4584756 3844304 8950953 9991568 TO PROVIDE HEALTH AND WELFARE BENEFITS FOR COVERED EMPLOYEES IN ACCORDANCE WITH THE PLAN. 0 0 11427197 TO PROVIDE HEALTH AND WELFARE BENEFITS FOR COVERED EMPLOYEES IN ACCORDANCE WITH THE PLAN. 11427197 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 1 0 1 0 0 0 0 0 0 0 0 0 0 0 X 6 0 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 0 0 0 X ZENITH AMERICAN SOLUTIONS 5095345625 111 WEST CATALDO AVENUE SUITE 220 SPOKANE WA 99201 X DANNY MA OUTGOING CHAIRMAN 1.00 40.00 X X 0 0 0 NICOLAI COCERGINE CHAIRMAN 1.00 40.00 X X 0 82486 14000 KATINA WOOD TRUSTEE 1.00 40.00 X 0 0 0 STEFANIE GUSHA SECRETARY 1.00 40.00 X X 0 0 0 SARA THODY TRUSTEE 1.00 40.00 X 0 51106 14000 TERRIE TRETTENBACH TRUSTEE 1.00 40.00 X 0 59546 14000 BOB MCLAUCHLIN TRUSTEE 1.00 40.00 X 0 0 0 0 193138 42000 0 0 0 0 MEDICAL REHABILITATION CONSULTANTS INC 111 WEST CATALDO AVE SUITE 200 SPOKANE WA 99201 HEALTH CARE MANAGEMENT 330240 ZENITH AMERICAN SOLUTIONS INC 11724 NE 195TH ST SUITE 300 BOTHELL WA 98011 CONTRACT ADMINISTRATION 319569 2 EMPLOYER CONTRIBUTIONS 445100 11389535 11389535 EMPLOYEE CONTRIBUTIONS 445100 706104 706104 12095639 22839 22839 PRESCRIPTION REBATES 445100 360188 360188 LIQUIDATED DAMAGES 445100 10323 10323 370511 12488989 12466150 0 22839 10409702 10409702 316848 316848 54015 54015 30817 30817 1724 1724 558584 558584 34873 34873 7187 7187 BANK SERVICE FEES 12135 12135 MISCELLANEOUS 1312 1312 11427197 11427197 0 0 7122300 7456669 1184684 1149627 389 176 5228336 5229400 13535709 13835872 43424 33530 4541332 3810774 4584756 3844304 X 0 0 0 0 8950953 9991568 8950953 9991568 13535709 13835872 1061792 -21177 0 X 0 0 0 0 CHECKS ISSUED IN EXCESS OF DEPOSITS 432665 AMOUNTS CURRENTLY PAYABLE TO/FOR PARTICIPANTS, BENEFICIARIES, AND DEPENDENTS 187909 OTHER OBLIGATIONS FOR CURRENT BENEFIT COVERAGE, AT PV OF ESTIMATED AMOUNTS 3190200 3810774 X 12466088 -21177 -21177 12487265 1724 1724 12488989 12280342 0 12280342 1724 -854869 -853145 11427197 PART X, LINE 2: THE UNITED STATES TREASURY DEPARTMENT ADVISED IN A LETTER DATED APRIL 27, 1971, THAT THE PLAN IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(9) OF THE INTERNAL REVENUE CODE (IRC). THE PLAN HAS BEEN AMENDED SINCE RECEIVING THE DETERMINATION LETTER. THE BOARD OF TRUSTEES BELIEVES THE PLAN, AS AMENDED, CONTINUES TO QUALIFY AND TO OPERATE IN ACCORDANCE WITH APPLICABLE PROVISIONS OF THE IRC. 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 ORGANIZATION HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE (IRS). THE PLAN ADMINISTRATOR HAS ANALYZED THE TAX POSITIONS TAKEN BY THE PLAN, AND HAS CONCLUDED THAT AS OF SEPTEMBER 30, 2021, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF THE LIABILITY (OR ASSET) OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS AND THE PLAN COULD BE SUBJECT TO INCOME TAX IF CERTAIN ISSUES WERE FOUND BY THE IRS THAT COULD RESULT IN THE DISQUALIFICATION OF THE PLAN'S TAX-EXEMPT STATUS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN AMOUNTS DUE TO INSURANCE COMPANY -172,069. CHANGE IN CLAIMS IBNR -695,000. CHANGE IN LIABILITY FOR FUTURE BENEFITS 12,200. FORM 990, PART VI, SECTION A, LINE 3 THE PLAN CONTRACTS WITH A THIRD-PARTY ADMINISTRATOR, ZENITH AMERICAN SOLUTIONS, INC., TO CARRY OUT THE DAY TO DAY ADMINISTRATION OF THE PLAN. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF FORM 990 WAS PROVIDED TO THE BOARD AND REVIEWED BY THE BOARD BEFORE ITS FILING. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL LETTERS ARE MAILED AND COLLECTED FROM EACH TRUSTEE. TRUST COUNSEL ASKS FOR ANY KNOWN ISSUES AT EACH TRUSTEE MEETING. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, FINANCIAL STATEMENTS AND OTHER DOCUMENTS ARE AVAILABLE UPON REQUEST THROUGH THE PLAN'S ADMINISTRATOR. FORM 990, PART VII, SECTION A, LINE 1A: TRUSTEES ARE NOT COMPENSATED BY THE FILING ORGANIZATION. CERTAIN TRUSTEES ARE EMPLOYED BY FOR-PROFIT CONTRIBUTING EMPLOYERS, WHICH ARE DEFINED AS RELATED PARTIES IN THE INSTRUCTIONS TO SCHEDULE R. PER THE VOLUNTEER EXCEPTION IN THE INSTRUCTIONS TO FORM 990, THIS COMPENSATION IS NOT REPORTABLE IN PART VII OF FORM 990 AS RELATED-ORGANIZATION COMPENSATION. UFCW LOCAL 4 UFCW LOCAL 8 INTERMOUNTAIN RETAIL STORE EMPLOYEES PENSION PLAN 111 W CATALDO SUITE 220 SPOKANE WA 99201 916187192 MULTIEMPLOYER PENSION PLAN MT 501(C)(5) 0 ALBERTSON'S LLC C & S JONES GROUP LLC B & B KALISPELL BIG SKY OPTICAL BOB WARD & SONS INC CASCADE WHOLESALE MEATS LICINIS PRINT SHOP ROSAUERS SAFEWAY SHEEP SHEARERS MERCH SMITH'S FOOD & DRUG CENTERS VAN'S THRIFTWAY WESTERN MEAT & SAUSAGE BLOCK 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1