2022-10-08T15:18:30-05:00 2021-12-31 222027092 WITHUMSMITHBROWN PC 5000 EXECUTIVE PARKWAY SUITE 400 SAN RAMON CA 94583 990 2021-01-01 946080365 SOUTH BAY HOTEL EMPLOYEES RESTAURANT EMPLOYEES WELFARE TRUST FUND SOUT 2064417574 PO BOX 34203 SEATTLE WA 98124 ENRIQUE FERNANDEZ CHAIRMAN 2064417574 2022-10-08 1 ENRIQUE FERNANDEZ 999009999 JOSEPH M THIERMANN P01066616 9252779100 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z ENRIQUE FERNANDEZ PO BOX 34203 SEATTLE WA 98124 36718886 0 X WWW.SOUTHBAYHERETRUST.COM X 1958 CA PROVIDE HEALTH AND WELFARE BENEFITS 8 0 0 0 0 0 0 0 25980946 29469855 1166193 2118499 0 0 27147139 31588354 0 0 32998335 25856903 0 0 0 0 0 1297319 1070786 34295654 26927689 -7148515 4660665 41565649 47078146 6296107 7694094 35269542 39384052 TO PROVIDE MEDICAL, LIFE, DENTAL, VISION, PRESCRIPTION DRUG, AND ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS FOR ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS. 0 0 PROVIDED MEDICAL, LIFE, DENTAL, VISION, PRESCRIPTION DRUG, AND ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS FOR ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS. 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 10 0 1 0 0 0 0 0 0 0 0 0 X 8 0 0 1 0 0 0 0 0 1 0 0 0 1 1 0 0 1 1 0 0 0 X WELFARE & PENSION ADMIN SERVICE 2064417574 7525 SE 24TH STREET STE 200 MERCER ISLAND WA 98040 X TANYA FLEMING TRUSTEE 0.50 X 0 0 0 JOHN SOUTHWELL SECRETARY 0.50 X 0 0 0 JACKIE DACANAY TRUSTEE - PAST 0.50 X 0 0 0 SARAH JULIAN TRUSTEE 0.50 X 0 0 0 ENRIQUE FERNANDEZ TRUSTEE 0.50 X 0 0 0 ROSA RODRIGUEZ TRUSTEE 0.50 X 0 0 0 SARAH MCDERMOTT ALTERNATE 0.50 X 0 0 0 RAQUEL ALVAREZ TRUSTEE 0.50 X 0 0 0 JIM BEARD TRUSTEE 0.50 X 0 0 0 JIMMY SARFRAZ TRUSTEE 0.50 X 0 0 0 SEE SCHEDULE O FOR COMPENSATION PAID BY RELATED ORGANIZATIONS 0.00 X 0 1 0 0 1 0 0 0 0 0 WELFARE & PENSION ADMINISTRATIVE SERVICE PO BOX 34203 SEATTLE WA 98124 THIRD PARTY ADMINISTRATIVE SERVICE PROVI 570449 AETNA 515 S FLOWER STREET SUITE 505 LOS ANGELES CA 90071 CLAIMS PROCESSING 171278 2 EMPLOYER CONTRIBUTIONS 900099 24758623 24758623 COBRA GOV'T SUBSIDY 900099 3589110 3589110 STOP LOSS REIMBURSEMENTS 900099 496690 496690 EMPLOYEE CONTRIBUTIONS 900099 394967 394967 FORMULARY REBATES 900099 160150 160150 70315 70315 29469855 1488344 1488344 5760687 5130532 630155 630155 630155 31588354 29469855 0 2118499 25856903 710738 15000 24406 70313 108500 108014 4992 880 27943 26927689 2866502 5868454 2252591 6176322 13152 14256 36433404 35019114 41565649 47078146 53107 70094 6243000 7624000 6296107 7694094 X 0 0 0 0 35269542 39384052 35269542 39384052 41565649 47078146 4660665 -546155 0 X X 0 1 X 1 0 0 ACCUMULATED ELIGIBILITY CREDITS 5592000 CLAIMS PAYABLE AND IBNR 1757000 INSURANCE PREMIUMS PAYABLE 275000 7624000 X 30971886 -546155 -546155 31518041 70313 70313 31588354 25476376 0 25476376 70313 1381000 1451313 26927689 PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE THE TAX POSITIONS TAKEN BY THE FUND AND TO RECOGNIZE A TAX LIABILITY IF THE FUND HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE PLAN AND HAS CONCLUDED THAT, AS OF DECEMBER 31, 2021, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE FUND IS SUBJECT TO ROUTINE AUDITS BY THE TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE FUND BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR THE FISCAL YEARS PRIOR TO 2018. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN BENEFIT OBLIGATIONS 1,381,000. FORM 990, PART VI, SECTION A, LINE 3 THE PLAN HAS CONTRACTED WITH WELFARE & PENSION ADMINISTRATION SERVICE, INC. TO PROVIDE ADMINISTRATIVE SERVICES FOR THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 8B THE BOARD OF TRUSTEES DOES NOT CURRENTLY HAVE SUB-COMMITTEES. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF THE FORM 990 WAS PROVIDED TO THE BOARD OF TRUSTEES FOR REVIEW BEFORE IT WAS FILED. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT-OF-INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION A, LINE 1A TRUSTEES ARE NOT COMPENSATED BY THE TRUST. COMPENSATION PAID TO THE TRUSTEES EMPLOYED BY OTHER RELATED ORGANIZATIONS IS REPORTED ON THE FORM 990 FILED WITH THE INTERNAL REVENUE SERVICE BY THE RELATED TAX-EXEMPT ORGANIZATION. IF YOU WOULD LIKE ADDITIONAL INFORMATION, PLEASE CONTACT THE THIRD-PARTY ADMINISTRATORS, WELFARE & PENSION ADMINISTRATION SERVICE, INC. FORM 990, PART XII, LINE 2C: THE ORGANIZATION HAS A BOARD OF TRUSTEES THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT AUDITOR. THIS PROCESS HAS NOT CHANGED. SOUTH BAY HERE TRAINING FUND PO BOX 34203 SEATTLE WA 98124 946535776 TRAINING PROGRAM CA 501(C)(9) N/A N/A 0 SOUTH BAY HERE LEGAL TRUST FUND PO BOX 34203 SEATTLE WA 98124 946535777 LEGAL SERVICES CA 501(C)(9) N/A N/A 0 HOTEL EMPLOYEES RESTAURANT EMPLOYEES LOC 19 2302 ZANKER ROAD SAN JOSE CA 95131 942300756 LABOR ORGANIZATION CA 501(C)(5) N/A N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 SCHEDULE R, IDENTIFICATION OF RELATED ORGANIZATIONS: THE FILING ORGANIZATION IS A TAFT-HARTLEY MULTIEMPLOYER PLAN THAT PROVIDES HEALTH AND WELFARE BENEFITS TO ELIGIBLE EMPLOYEES AND THEIR DEPENDENTS. AS OF DECEMBER 31, 2021, THERE ARE APPROXIMATELY 33 EMPLOYERS THAT CONTRIBUTE TO THE TRUST. THE ADMINISTRATIVE OFFICE MAINTAINS A DATABASE OF THESE CONTRIBUTING EMPLOYERS, INCLUDING NAMES, ADDRESSES AND OTHER CONTACT INFORMATION. THE FEDERAL TAX CLASSIFICATION (DISREGARDED ENTITY, TAX EXEMPT ORGANZATION, PARTNERSHIP, TAXABLE CORPORATION OR TRUST) FOR EACH CONTRIBUTING EMPLOYER IS NOT ON FILE WITH THE ADMINISTRATIVE OFFICE AND IT COULD NOT BE REASONABLY OBTAINED. AS A RESULT THE NAMES OF THE CONTRIBUTING EMPLOYERS ARE LISTED ON PART VII BELOW AND NOT ON PARTS II THROUGH IV BY FEDERAL TAX CLASSIFICATION. 4 POINTS BY SHERATON ARAMARK @CISCO SYSTEMS BALANCE POINT BAY 101 CLUB COMPASS GROUP DBA COMPASS LOCKHEED MART DOLCE INT'L/SAN JOSE DOUBLETREE HOTEL SJ EUREST @VERIZON MEDIA EUREST AT INTEL FAIRMONT HOTEL FLAGSHIP FACILITY FOURTH STREET BOWL HERE LOCAL 19 HOLIDAY INN SJ AIRPORT HOST INTERNATIONAL INC HOTEL DE ANZA HUDSON GROUP HYATT PLACE SAN JOSE LEVY RESTAURANTS LEVY RESTAURANTS AT MADONNA INN-C/O SMHERE MARRIOTT SAN JOSE ORIGINAL JOE'S/T.MULFO SAN JOSE ARENA-ARAMARK SAN JOSE HILTON & TOWE SANTA CLARA HILTON SODEXO, INC TEAM SAN JOSE THE VISALIA MARRIOTT THE WESTIN SAN JOSE WORLD DUTY FREE GROUP WELFARE PENSION & ADMINISTRATION SERVICE, INC.