2021-10-12T14:12:41-05:00 2020-11-30 363168081 SIKICH LLP 13400 BISHOPS LANE SUITE 300 BROOKFIELD WI 53005 990 2019-12-01 390979166 UNITED FOOD & COMMERCIAL WORKERS UNIONS & EMPLOYERS HEALTH PLAN UNIT 4144762523 2001 NORTH MAYFAIR ROAD MILWAUKEE WI 53226 JACOB BAILEY CHAIRMAN 4144762523 2021-10-11 1 JAMES B BOUTELLE CPA P01794129 2627549400 2021-10-04 2019 2022-09-23 18:48:47Z JACOB BAILEY 2001 NORTH MAYFAIR ROAD MILWAUKEE WI 53226 2679682 0 X N/A X 1960 WI HEALTH PLAN 7 3 0 3 0 0 0 0 2153823 2634437 7579 45245 2500 0 2163902 2679682 0 0 1930004 2223197 0 0 0 0 0 426879 458901 2356883 2682098 -192981 -2416 2963942 2974209 387781 242047 2576161 2732162 TO PROVIDE ELIGIBLE PARTICIPANTS ACCIDENT, HEALTH, VISION, DENTAL, PRESCRIPTION DRUG, LIFE INSURANCE, LOSS OF TIME, AND ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS. 0 0 ACCIDENT, HEALTH, LOSS-OF-TIME, DENTAL, LIFE, VISION CARE BENEFIT PAYMENTS TO PARTICIPANTS. PRESCRIPTION DRUG PROGRAM BENEFITS PAID ON BEHALF OF PARTICIPANTS. LIFE INSURANCE BENEFITS PAID ON BEHALF OF PARTICIPANTS. 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 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 X 7 3 1 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 X ZENITH AMERICAN SOLUTIONS 4144761220 2001 NORTH MAYFAIR ROAD MILWAUKEE WI 53226 JOHN EIDEN - RESIGNED 53121 CHAIRMAN/UNION TRUSTEE 1.00 40.00 X X 0 141844 18435 GRANT WITHERS - RESIGNED UNION TRUSTEE 1.00 40.00 X 0 129981 18435 JACOB BAILEY UNION TRUSTEE 1.00 40.00 X 0 110114 18435 CHAD WHITESIDE ALTERNATE UNION TRUSTEE 1.00 40.00 X 0 110273 18435 MELANIE BARTHOLF ALTERNATE UNION TRUSTEE 1.00 40.00 X 0 81704 18435 DARREN HORNDASCH SECRETARY/EMPLOYER TRUSTEE 1.00 X X 0 0 0 PAUL BUTERA SR - RESIGNED EMPLOYER TRUSTEE 1.00 X 0 0 0 PAUL BUTERA JR EMPLOYER TRUSTEE 1.00 X 0 0 0 JUDITH BUTERA - RESIGNED ALTERNATE EMPLOYER TRUSTEE 1.00 X 0 0 0 TIMOTHY LAMERS EMPLOYER TRUSTEE 1.00 X 0 0 0 0 573916 92175 0 0 1 0 0 EMPLOYER CONTRIBUTIONS 525100 2617663 2617663 SELF PAY CONTRIBUTIONS 525100 16774 16774 2634437 45245 45245 2679682 2634437 0 45245 2223197 90000 49257 82121 5337 282 7807 STOP LOSS PREMIUMS 97821 ACCIDENT & HEALTH FEES 88837 BANK SERVICE FEES 17534 PROGRAM EXPENSE 10558 9347 2682098 918954 736332 2922 2922 11220 2358 6074 4163 2024772 2228434 2963942 2974209 136240 39803 61541 87144 190000 115100 387781 242047 X 0 0 0 0 2576161 2732162 2576161 2732162 2963942 2974209 -2416 158417 0 X 0 1 X 1 0 0 CLAIMS PAYABLE 115100 115100 X 2838099 158417 158417 2679682 0 2679682 2756998 74900 74900 2682098 0 2682098 PART X, LINE 2: THE TRUST ESTABLISHED UNDER THE PLAN TO HOLD THE PLAN'S ASSETS IS INTENDED TO QUALIFY PURSUANT TO SECTION 501(C)(9) OF THE INTERNAL REVENUE CODE (IRC) AND IS THEREFORE NOT SUBJECT TO TAX UNDER PRESENT INCOME TAX LAWS. THE TRUST HAS OBTAINED A FAVORABLE TAX EXEMPTION LETTER FROM THE INTERNAL REVENUE SERVICE (IRS), AND THE PLAN SPONSOR BELIEVES THAT THE TRUST AND THE PLAN, AS AMENDED, CONTINUE TO QUALIFY AND TO OPERATE IN ACCORDANCE WITH APPLICABLE PROVISIONS OF THE IRC. U.S. GAAP 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 TAX POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. PART XII, LINE 2D - OTHER ADJUSTMENTS: DECREASE IN CURRENT YEAR CLAIMS PAYABLE 74,900. 0 0 0 JOHN EIDEN - RESIGNED 53121 CHAIRMAN/UNION TRUSTEE 0 141844 0 0 0 0 0 0 0 18435 0 160279 0 0 FORM 990, PART VI, SECTION A, LINE 2 PAUL BUTERA SR., PAUL BUTERA JR., AND JUDITH BUTERA HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PROVIDED TO THE FUND'S RECORDKEEPER. THEY REVIEW IT AND APPROVE IT, THEN PRESENT THE FORM 990 TO THE BOARD OF TRUSTEES FOR REVIEW AND FILING APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 THEY ARE AVAILABLE UPON REQUEST. UNITED FOOD AND COMMERCIAL WORKERS LOCAL 1473 2001 NORTH MAYFAIR ROAD MILWAUKEE WI 53226 562585698 LABOR UNION WI 501(C)(5) N/A 0 BOARD OF TRUSTEES OF WI UFCW UNIONS AND EMPLOYERS HEALTH PLAN 2001 NORTH MAYFAIR ROAD MILWAUKEE WI 53226 390979166 PLAN SPONSOR AND PLAN ADMINISTRATOR WI 501(C)(9) N/A 0 OFFICE SOLUTIONS - USA INC UNION FIRST LASER TECHNOLOGIES INC PIGGLY WIGGLY MIDWEST SUPERIOR NATIONAL BANK & TRUST COMPANY STINEBRINK'S PIGGLY WIGGLY WISCONSIN VISION FRED USINGER INC 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0