2021-02-15T15:24:42-06:00 2020-09-27 420714325 RSM US LLP 400 LOCUST ST STE 640 DES MOINES IA 503092372 990 2019-09-30 421170511 HY-VEE AND AFFILIATES' BENEFIT PLAN AND TRUST HY-V 5152672800 5820 WESTOWN PARKWAY WEST DES MOINES IA 50266 MICHAEL SKOKAN TRUSTEE 5152672800 2021-02-15 1 TY P DOGGETT P00810916 5155586600 2021-02-15 2019 2022-09-23 18:48:47Z MICHAEL SKOKAN 5820 WESTOWN PARKWAY WEST DES MOINES IA 50266 200252040 0 X N/A X 1981 IA IT IS THE MISSION OF THE HY-VEE AND AFFILIATES BENEFIT PLAN TO MAKE EMPLOYEE'S LIVES EASIER, HEALTHIER, AND HAPPIER BY PROVIDING FOR THE HEALTH AND RELATED BENEFIT NEEDS OF THE ADOPTING COMPANIES' EMPLOYEES AND THEIR DEPENDENTS. 3 0 0 4 64506 57947 0 0 205658571 200187534 226775 64506 0 0 205885346 200252040 0 0 190877086 187135610 0 0 0 0 0 12979692 12382639 203856778 199518249 2028568 733791 29169011 29863544 25356205 23895614 3812806 5967930 TO PROVIDE QUALITY, COST-EFFECTIVE AND COMPREHENSIVE MEDICAL, DENTAL, LIFE AND DISABILITY BENEFITS; TO PROVIDE MEANINGFUL INFORMATION, RESOURCES, AND ASSISTANCE; AND TO PROVIDE PREVENTIVE AND WELLNESS-RELATED INTERVENTIONS AND PROGRAMS. 0 0 THIS TRUST IS ESTABLISHED TO PROVIDE FOR THE HEALTH AND RELATED BENEFIT NEEDS OF THE ADOPTING COMPANIES' EMPLOYEES AND THEIR DEPENDENTS. DURING THE PLAN YEAR ENDED SEPTEMBER 27, 2020, THE PLAN PROVIDED BENEFITS TO 16,645 EMPLOYEES. 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 0 0 0 1 1 0 0 0 0 0 0 0 X 3 0 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X X MICHAEL SKOKAN 5152672800 5820 WESTOWN PARKWAY WEST DES MOINES IA 50266 X X SHEILA LAING TRUSTEE 1.00 40.00 X 0 0 0 KRISTINE JONES TRUSTEE 1.00 40.00 X 0 0 0 MICHAEL SKOKAN TRUSTEE 1.00 40.00 X 0 0 0 GEORGIA VAN GUNDY TRUSTEE 1.00 40.00 X 0 0 0 0 0 0 0 0 0 0 WELLMARK INC 636 GRAND AVE DES MOINES IA 503092565 CONTRACT ADMINISTRATOR 9977992 DELTA DENTAL 2401 SE TONES DR 13 ANKENY IA 500218665 ADMINISTRATOR 652899 HEALTH PARTNERS 8170 33RD AVENUE MINNEAPOLIS MN 55440 ADMINISTRATOR 539337 HARTFORD LIFE & ACCIDENT INSURANCE COMPA 200 HOPMEADOW STREET SIMSBURY CT 06089 ADMINISTRATOR 448911 CERNER CORPORATION 2800 ROCKCREEK PARKWAY NORTH KANSAS CITY MO 64117 CONSULTING SERVICES 315464 7 EMPLOYER CONTRIBUTIONS 525100 152190269 152190269 EMPLOYEE CONTRIBUTIONS 525100 47997265 47997265 200187534 64506 64506 200252040 200187534 64506 0 187135610 11942378 413235 INCOME TAXES 21766 MISCELLANEOUS EXPENSES 5260 199518249 14855 774364 21663000 20090000 7047798 8652433 356188 259577 87170 87170 29169011 29863544 4432192 4392934 20924013 19502680 25356205 23895614 X 3812806 5967930 0 0 0 0 3812806 5967930 29169011 29863544 X 733791 1421333 X 0 1 X 0 0 0 BENEFIT OBLIGATIONS 19502680 19502680 X 200252040 0 200252040 0 200252040 199518249 0 199518249 0 199518249 PART X, LINE 2: THE TRUST ESTABLISHED UNDER THE PLAN TO HOLD THE PLAN'S NET ASSETS IS QUALIFIED PURSUANT TO SECTION 501(C)(9) OF THE INTERNAL REVENUE CODE AND, ACCORDINGLY, THE TRUST'S NET INVESTMENT INCOME IS EXEMPT FROM INCOME TAXES. THE SPONSOR HAS OBTAINED A FAVORABLE TAX DETERMINATION LETTER DATED MAY 18, 1982 FROM THE INTERNAL REVENUE SERVICE AND THE SPONSOR BELIEVES THAT THE TRUST, AS AMENDED, CONTINUES TO QUALIFY AND TO OPERATE AS DESIGNED. MANAGEMENT HAS EVALUATED THE PLAN'S TAX POSITIONS AND CONCLUDED THAT THE PLAN HAS MAINTAINED ITS TAX EXEMPT STATUS AND HAS TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENTS TO THE FINANCIAL STATEMENTS. GENERALLY, THE STATUTE OF LIMITATIONS FOR EXAMINATION OF U.S. FEDERAL OR STATE TAX RETURNS IS THREE YEARS AND IS CONSIDERED CLOSED UPON REVIEW BY THE TAXING JURISDICTION. FORM 990, PART VI, SECTION A, LINE 2 THE TRUSTEES HAVE A BUSINESS RELATIONSHIP AS THEY ARE EMPLOYED BY THE SAME COMPANY. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF THE FINAL FORM 990, AS FILED WITH THE IRS, IS PROVIDED TO THE TRUSTEES PRIOR TO FILING THE FORM. THE TRUSTEES ARE AVAILABLE FOR REVIEW PRIOR TO FILING THE FORM. FORM 990, PART VI, SECTION B, LINE 12C HY-VEE AND AFFILIATES' BENEFIT PLAN AND TRUST HAS A CONFLICT OF INTEREST POLICY. TRUSTEES ANNUALLY COMPLETE AND SIGN A CONFLICT OF INTEREST STATEMENT. TO THE EXTENT A TRUSTEE HAS A CONFLICT OF INTEREST, THEY LEAVE THE ROOM AND ABSTAIN FROM VOTING ON SUCH MATTER. IDENTIFIED CONFLICT OF INTEREST SITUATIONS AND DELIBERATIONS ARE CONTEMPORANEOUSLY DOCUMENTED IN THE MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST FOR VIEWING IN THE OFFICE OF THE PLAN ADMINISTRATOR. THE FORM 990 IS AVAILABLE ON GUIDESTAR.ORG. FORM 990, PART VII, SECTION A, LINE 1A(B): THE TRUSTEES ARE EMPLOYEES OF THE RELATED ORGANIZATION AND SERVE AS VOLUNTEER TRUSTEES FOR THE ORGANIZATION. FORM 990, PART XI, LINE 9: ADJUSTMENT TO BENEFIT OBLIGATIONS 1,421,333. HY-VEE INC 5820 WESTOWN PARKWAY WEST DES MOINES IA 50266 420325638 RETAIL SALES IA N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1