2022-11-15T11:56:06-06:00 2021-12-31 133418879 GETTRY MARCUS CPA PC 201 OLD COUNTRY RD SUITE 202 MELVILLE NY 11747 990 2021-01-01 136179467 LOCAL 475 HEALTH PLAN LOCA 9147386555 629 FIFTH AVENUE PELHAM NY 10803 PETER VAUPEL FUND ADMINISTRATOR 9147386555 2022-11-15 1 PETER VAUPEL 999009999 ANDREW ZWERMAN CPA P00641815 6317771000 2022-11-15 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z 629 FIFTH AVENUE PELHAM NY 10803 8728741 0 X N/A X 1965 NY EMPLOYER CONTRIBUTIONS PROVIDE HEALTH & WELFARE BENEFITS TO PARTICIPANTS IN THE PLAN. 3 1 4 0 0 0 0 0 7006017 6997093 173847 231649 0 0 7179864 7228742 0 0 3889164 5839327 191975 189530 0 0 0 844355 811113 4925494 6839970 2254370 388772 12349764 15003775 684124 1914325 11665640 13089450 EMPLOYER CONTRIBUTIONS PROVIDE HEALTH & WELFARE BENEFITS TO PARTICIPANTS IN THE PLAN. 0 0 EMPLOYER CONTRIBUTIONS PROVIDE HEALTH & WELFARE BENEFITS TO PARTICIPANTS IN THE PLAN. 0 0 0 0 0 0 0 0 0 1 0 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 0 1 4 0 1 4 1 0 0 0 0 0 0 0 0 0 0 X 3 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X SILVIA PEREZ 9147386555 629 FIFTH AVE PELHAM NY 10803 PETER VAUPEL FUND ADMIN 19.00 21.00 X 68962 73935 13055 RONALD KOWALSKI JR TRUSTEE 0.00 X 0 0 0 EDUARDO MELENDEZ TRUSTEE 17.00 23.00 X 35697 45821 13054 104659 119756 26109 0 0 1 0 ANTHEM INC PO BOX 951254 CLEVELAND OH 44193 ADMINISTRATIVE FEES 110909 1 EMPLOYER CONTRIBUTIONS 900099 6967150 6967150 COBRA CONTRIBUTIONS 900099 29943 29943 6997093 179855 179855 1551793 1499999 51794 51794 51794 7228742 7228742 0 0 5839327 104659 36321 37201 11349 21600 24664 12121 20000 18429 25839 7532 5622 STOP LOSS PREMIUMS 386146 CLAIMS PROCESSING FEES 289160 6839970 1439202 1219547 9928 9929 356752 499541 22437 22437 0 0 10498192 13264878 45690 9880 12349764 15003775 140124 192325 544000 1722000 684124 1914325 X 0 0 0 0 11665640 13089450 11665640 13089450 12349764 15003775 388772 1035038 0 X 0 1 X 1 0 22437 22437 0 0 BENEFITS PAYABLE AND IBNR 1722000 1722000 X 8251659 1035038 1035038 7216621 12121 12121 7228742 5649849 0 5649849 12121 1178000 1190121 6839970 PART X, LINE 2: THE PLAN ADMINISTRATOR HAS ANALYZED THE TAX POSITIONS TAKEN BY THE PLAN, AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2020 AND 2019, 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. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROCESS. BASED ON THE NORMAL STATUTORY PERIOD FOR AUDITS, THE PLAN ADMINISTRATOR BELIEVES THAT THE TAX RETURNS OF THE PLAN FOR THE YEARS PRIOR TO THE YEAR ENDED DECEMBER 31, 2017 ARE NO LONGER OPEN TO EXAMINATION, NOTWITHSTANDING ANY INFORMATION NOT YET KNOWN WHICH COULD EXPAND THE OPEN PERIOD. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN BENEFITS PAYABLE AND CLAIMS INCURRED BUT NOT REPORTED 0 0 0 PETER VAUPEL FUND ADMIN 68962 73935 0 0 0 0 0 0 5984 7071 74946 81006 0 0 FORM 990, PART VI, SECTION B, LINE 11B LINE 11B EXPLANATION - FORM 990 WAS SENT TO THE TRUSTEES FOR REVIEW. UPON APPROVAL, A WAIVER IS SIGNED AUTHORIZING THE ELECTRONIC SUBMISSION OF THE FORM. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY AT THE BOARD OF TRUSTEE MEETINGS. FORM 990, PART VI, SECTION B, LINE 15 INCREASES IN COMPENSATION ARE APPROVED BY THE BOARD AND ARE COMPARED TO INDUSTRY STANDARDS. FORM 990, PART VI, SECTION C, LINE 19 UPON REQUEST, GOVERNING DOCUMENTS, POLICIES, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC. LOCAL 475 PENSION PLAN 629 FIFTH AVENUE PELHAM NY 10803 132571151 TO PROVIDE PENSION BENEFITS TO MEMBERS NY 401- (A) N/A 0 STAFF RETIREMENT PLAN OF LOCAL 475 629 FIFTH AVENUE PELHAM NY 10803 132996854 TO PROVIDE SUPPLEMENTAL RETIREMENT BENEFITS NY 401- (A) N/A 0 IUEW LOCAL 475 629 FIFTH AVENUE PELHAM NY 10803 131654293 BETTERMENT OF WAGES AND WORKING CONDITIONS NY 501 (C) 5 N/A 0 DELTA DENTAL OF NEW JERSEY 1639 ROUTE 10 PARSIPPANY NJ 07054 CONTRIBUTING EMPLOYER NJ N/A 0 CHROMALLOY NEW YORK 330 BLAISDELL ROAD ORANGEBURG NY 10962 CONTRIBUTING EMPLOYER NY N/A 0 C W BRABENDER INSTRUMENTS INC 50 E WESLEY STREET S HACKENSACK NJ 07604 CONTRIBUTING EMPLOYER NJ N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0