2022-11-10T14:06:19-06:00 2021-12-31 222027092 WITHUMSMITHBROWN PC 5000 EXECUTIVE PARKWAY SUITE 400 SAN RAMON CA 94583 990 2021-01-01 776113549 NORTHERN CALIFORNIA SHEET METAL WORKERS HEALTH CARE PLAN NORT 9252089992 3240B CONSTITUTION DRIVE LIVERMORE CA 94551 SAL ROTOLO TRUSTEE 9252089992 2022-11-10 1 SAL ROTOLO 999009999 JESSICA R ROSTER P01317380 9252779100 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z SAL ROTOLO PO BOX 1677 SAN RAMON CA 94583 29268156 0 X N/A X 1995 CA TO PROVIDE HEALTH AND WELFARE BENEFITS. 8 0 0 0 0 0 0 0 28655760 28832357 440980 417946 0 17853 29096740 29268156 0 0 24723754 27594186 0 0 0 0 0 1564352 1551573 26288106 29145759 2808634 122397 30520368 31126708 10079978 9971017 20440390 21155691 TO PROVIDE HEALTH AND WELFARE BENEFITS 0 0 PROVIDED HEALTH AND WELFARE BENEFITS TO ELIGIBLE PARTICIPANTS COVERED UNDER THE COLLECTIVE BARGAINING AGREEMENTS BETWEEN THE UNION AND EMPLOYERS. 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 5 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 1 1 1 1 0 0 0 X BENESYS INC 9252089992 3240B CONSTITUTION DRIVE LIVERMORE CA 94551 X SAL ROTOLO CHAIR / TRUSTEE 2.00 X 0 0 0 JIM CONWAY CO-CHAIR / TRUSTEE 2.00 X 0 0 0 RICK WERNER TRUSTEE 2.00 X 0 0 0 MIKE LOPEZ TRUSTEE 2.00 X 0 0 0 DUSTIN SACCONE TRUSTEE 2.00 X 0 0 0 CHRIS MAY TRUSTEE 2.00 X 0 0 0 MICHAEL MARK TRUSTEE 2.00 X 0 0 0 GARY MYERS TRUSTEE 2.00 X 0 0 0 SEE SCHEDULE O FOR COMPENSATION PAID BY RELATED ORGANIZATIONS 1.00 X 0 1 0 0 1 0 0 0 0 0 BENESYS INC 3240B CONSTITUTION DRIVE LIVERMORE CA 94551 CONTRACT ADMINISTRATOR 903997 BLUE SHIELD 50 BEALE STREET 20TH FLOOR SAN FRANCISCO CA 94105 COST CONTAINMENT 204926 2 EMPLOYER CONTRIBUTIONS 900099 23398220 23398220 PARTICIPANT CONTRIBUTIONS 900099 4216799 4216799 PRESCRIPTION REBATES 900099 912259 912259 STOP LOSS INSURANCE RECOVERIES 900099 171998 171998 COBRA PREMIUM SUBSIDY 900099 70632 70632 62449 62449 28832357 417946 417946 OTHER INCOME 900099 17853 17853 17853 29268156 28850210 0 417946 27594186 859800 56514 36786 33535 492597 54473 500 17368 29145759 -159592 -71678 5636864 4765529 5208248 5582302 16317 23389 19818531 20827166 30520368 31126708 160658 183423 333320 321594 9586000 9466000 10079978 9971017 X 0 0 0 0 20440390 21155691 20440390 21155691 30520368 31126708 122397 592904 0 X X 0 1 X 1 0 0 ACCUMULATED ELIGIBILITY CREDITS 7883000 INCURRED BUT NOT REPORTED CLAIMS 1583000 9466000 X 29827525 592904 592904 29234621 33535 33535 29268156 29232224 0 29232224 33535 -120000 -86465 29145759 PART X, LINE 2: THE PLAN'S ADMINISTRATOR 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 PLAN IS SUBJECT TO ROUTINE AUDITS BY THE TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE PLAN'S ADMINISTRATOR BELIEVES THE PLAN IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR THE FISCAL YEARS PRIOR TO 2018. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHANGES IN BENEFIT OBLIGATIONS FORM 990, PART VI, SECTION A, LINE 3 THE TRUST HAS CONTRACTED WITH BENESYS, INC. TO PROVIDE ADMINISTRATIVE SERVICES FOR THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE A COMMITTEE WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF THE FORM 990 WAS PROVIDED TO EACH GOVERNING BODY MEMBER. REVIEW OF FORM 990 WAS CONDUCTED BY THE BOARD OF TRUSTEES (THE GOVERNING BOARD) PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, TRUSTEES ARE REQUIRED TO DISCLOSE IN WRITING ANY RELATIONSHIPS OR INTEREST THAT COULD GIVE RISE TO A CONFLICT. IF THERE IS A CONFLICT OF INTEREST, THE CONFLICTING INTEREST IS FULLY DISCLOSED AND DOCUMENTED IN WRITING; THE TRUSTEE OR FIDUCIARY WITH THE CONFLICT OF INTEREST IS EXCLUDED FROM THE DISCUSSION AND APPROVAL OF SUCH TRANSACTION; AND APPROVAL OF SUCH TRANSACTION IS DEPENDENT ON THE TRUSTEES DETERMINING THAT THE TRANSACTION IS IN THE BEST INTEREST OF THE TRUST AND THE TERMS OF THE TRANSACTION ARE FAIR WITH RESPECT TO TERMS AVAILABLE THROUGH ARMS-LENGTH TRANSACTIONS IN THE MARKETPLACE. FORM 990, PART VI, SECTION B, LINE 15 THE PLAN'S TRUSTEES ARE NOT PAID FOR THEIR SERVICES TO THE PLAN. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT-OF-INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. PART VII, SECTION A, LINE 1A: TRUSTEES ARE NOT COMPENSATED BY THE TRUST. COMPENSATION PAID TO TRUSTEES EMPLOYED BY OTHER RELATED ORGANIZATIONS IS REPORTED ON THE FORM 990 FILED WITH THE INTERNAL REVENUE SERIVCE BY THE RELATED TAX-EXEMPT ORGANIZATION. IF YOU WOULD LIKE ADDITIONAL INFORMATION, PLEASE CONTACT THE THIRD PARTY ADMINISTRATOR, BENESYS, INC. FORM 990, PART XII, LINE 2C: THE BOARD OF TRUSTEES ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT AUDITOR. THIS PROCESS HAS NOT CHANGED. SHEET METAL WORKERS LOCAL UNION NO 104 3232 CONSTITUTION DRIVE LIVERMORE CA 94551 940859420 LABOR UNION 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 0 0 0 SCHEDULE R, IDENTIFICATION OF RELATED ORGANIZATIONS: THE FILING ORGANIZATION IS A TAFT-HARTLEY MULTIEMPLOYER TRUST THAT PROVIDES HEALTH AND WELFARE BENEFITS TO ELIGIBLE EMPLOYEES AND THEIR DEPENDENTS. AS OF DECEMBER 31, 2021, THERE ARE APPROXIMATELY 100 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 ORGANIZATION, PARTNERSHIP, TAXABLE CORPORATION, OR TRUST) FOR EACH CONTRIBUTING EMPLOYER IS NOT ON FILE WITH THE ADMINISTRAIVE OFFICE AND IT COULD NOT BE REASONABLY OBTAINED. AS A RESULT, THE NAMES OF THE CONTRIBUTING EMPLOYERS ARE LISTED IN PART VII BELOW AND NOT ON PARTS II THROUGH IV BY FEDERAL TAX CLASSIFICATION. ABM BUILDING SOLUTIONS, LLC AIR AMERICAN, INC. ACCO ENGINEERED SYSTEMS AIR CONTROL BALANCE, INC. AIR SYSTEMS SERVICE & CONSTR. AIR SYSTEMS, INC. AIRCO MECHANICAL INC. AIRTEKS.COM, INC. AMERICAN MECHANICAL SYSTEMS B & L MECHANICAL, INC. B N MECHANICAL INC BEST CONTRACTING SERVICES CA DEPT PRISON-CDCR REG ACCTNG FSI BLOCKA INC. FRANK M BOOTH INC BOS SHEET METAL BRICE MECH. CONTRACTORS, INC. BROWN S/M & MECHANICAL CALIFORNIA CLIMATE SYSTEMS CALIFORNIA SHEET METAL CALIFORNIA UNITED MECH. INC. W A CALL MFG CO CAPITAL SHEET METAL WRK CENTER PLUMBING CO CERTIFIED AIR BALANCE CO. INC. CHAMPION INDUSTRIAL CONTR. CIRCO SYSTEM BALANCE, INC. COMFORT AIR, INC. B2 AIR SYSTEMS CRITCHFIELD MECHANICAL D & D ROOFING AND S.M., INC. DKM HEATING & A/C, INC. DDK MECHANICAL, INC. CA STATE OF PRISON-DEPT. OF DESERT MECHANICAL DUCTMATE IND INC EMCOR ARC SERVICE EMCOR MESA ENERGY SYSTEMS MCCLANAHAN, INC. MCCLELLAND AIR CONDITIONING FRED L HILL INDOOR ENVIRONMENTAL SERVICES INTECH MECHANICAL CO., LLC K & M INSTALLATION KINETICS MECH SERVICE INC. LAWSON MECHANICAL INC KEY AIR CONDITIONING JOHN W. MCDOUGALL CO., INC. M.E.S.A. 3, INC MELTON AIR CONDITIONING, INC. M2 ENERGY SERVICES, INC. NATIONAL AIR BALANCE NATIONAL ENERGY MGMT INST. CO JAMES LONG CONSTRUCTION SVC NICRO INC NIECO CORPORATION OTAVILLA MECHANICAL CONTR. INC PACIFIC TEST & BALANCE, INC. PACE PERFORMANCE CONSTRUCTION PAN-PACIFIC MECHANICAL PATTON SHEET METAL WORK PENN AIR CONTROL INC. PRIME MECHANICAL SERVICE, INC. RS ANALYSIS, INC. RAGLEN SYSTEM BALANCE RAM MECHANICAL, INC. RODRIGUEZ SHEET METAL NEW ENGLAND S/M AND MECH. CO. SACTO VALLEY APPR FUND RUTHERFORD CO., INC. KAMRAN METALWORKS, INC. SHEET METAL WORKERS 104 DIST 2 S/M IND JOINT APP COMM SMITH MECHANICAL-ELECT.-PLBG SMITH HEATING AIR COND SOUTHLAND INDUSTRIES SPECIALTY STAINLESS STARACE MECHANICAL CA DEPT PRISON-CDCR REG ACCTNG STRATEGIC MECHANICAL INC. HARRIS MOUNTAIN WEST, LLC RA MECHANICAL T.A.B.C.O. TECTA AMERICA SACRAMENTO, INC. THERMALAIR, INC. TOWN & COUNTRY HEATING & COOL. TOWN & COUNTRY HEATING AND TOP NOTCH MECHANICAL, INC. TOP NOTCH MECHANICAL, INC. WAGNER MECHANICAL WESTERN STATES COUNCIL J. BOONE MECHANICAL, INC. RECIP L023 RECIP L088 RECIP L104 RECIP L105 RECIP L273 SMW LU#273 RECIP L026 T-I LOCAL 104