2020-11-11T14:45:52-06:00 2019-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2019-01-01 363831874 MOSAIC EMPLOYEE WELFARE BENEFIT PLAN MOSA 4028963884 4980 SOUTH 118TH STREET NO A OMAHA NE 68137 SCOTT HOFFMAN CHIEF FINANCIAL OFFICER 4028963884 2020-11-09 1 WENDY R COOLEY P01523804 4023302660 209.34.201.180 2020-11-09 10:00:15 CS P AF8EF55A92B2310F3B808CD5150188985E494B03 5D066E2939FE45487034BD10C4A0DC94BE27FEF9 2019 2021-04-22 16:20:28Z SCOTT HOFFMAN 4980 SOUTH 118TH STREET NO A OMAHA NE 68137 20515569 0 X N/A X 1991 NE TO PROVIDE SELF-FUNDED HEALTH CARE, DENTAL CARE AND EDUCATION COMPENSATION BENEFITS TO PARTICIPANTS WHO ARE ELIGIBLE EMPLOYEES OR TO A COVERED DEPENDENT OF AN ELIGIBLE EMPLOYEE OF MOSAIC AND ITS AFFILIATES. 3 1 0 0 220506 0 0 0 17026825 17323544 229966 290795 0 0 17256791 17614339 0 0 16470287 18452599 0 0 0 0 0 3117694 2571474 19587981 21024073 -2331190 -3409734 9710148 6801438 1894904 1879585 7815244 4921853 TO PROVIDE SELF-FUNDED HEALTH CARE, DENTAL CARE AND EDUCATION COMPENSATION BENEFITS TO PARTICIPANTS WHO ARE ELIGIBLE EMPLOYEES OR TO A COVERED DEPENDENT OF AN ELIGIBLE EMPLOYEE OF MOSAIC AND ITS AFFILIATES. 0 0 COMPREHENSIVE MEDICAL AND DENTAL CARE, EMPLOYEE ASSISTANCE WITH MENTAL AND NERVOUS DISORDERS AND EDUCATION COMPENSATION BENEFITS FOR ELIGIBLE EMPLOYEES AND DEPENDENTS. THERE WERE 4,285 ELIGIBLE EMPLOYEES, OF WHICH 2,549 WERE PARTICIPATING IN THE PLAN DURING THIS CALENDAR YEAR. 0 0 0 0 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 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 X 3 1 0 0 0 0 0 0 0 1 1 1 0 1 1 1 1 1 1 0 0 0 X SCOTT HOFFMAN 4028963884 4980 S 118TH ST SUITE A OMAHA NE 68137 LINDA TIMMONS CHIEF EXECUTIVE OFFICER 0.10 39.90 X X 0 616682 160451 SCOTT HOFFMAN CHIEF FINANCIAL OFFICER 0.10 39.90 X X 0 314488 62501 GREAT WESTERN BANK TRUSTEE 0.10 X 0 0 0 0 931170 222952 0 0 1 0 0 EMPLOYER CONTRIBUTIONS 525100 12274594 12274594 EMPLOYEE CONTRIBUTIONS 525100 4409354 4409354 STOP LOSS INCOME 525100 639596 639596 17323544 220506 220506 2971519 2901230 70289 70289 70289 17614339 17323544 220506 70289 18452599 1266063 4200 6167 114830 STOP LOSS PREMIUMS 936185 WELLNESS 211309 LIFE INSURANCE PREMIUMS 32720 21024073 461499 1427429 2016533 527328 69746 66921 7162370 4779760 9710148 6801438 1894904 1879585 1894904 1879585 X 0 0 0 0 7815244 4921853 7815244 4921853 9710148 6801438 -3409734 521343 -5000 0 X 0 0 0 0 0 0 LINDA TIMMONS CHIEF EXECUTIVE OFFICER 0 487403 0 125000 0 4279 0 124663 0 35788 0 777133 0 0 SCOTT HOFFMAN CHIEF FINANCIAL OFFICER 0 273299 0 40000 0 1189 0 38213 0 24288 0 376989 0 0 PART I, LINE 3 THE SALARIES OF LINDA TIMMONS AND SCOTT HOFFMAN ARE PAID FROM A RELATED ORGANIZATION, MOSAIC. MS. TIMMONS SERVES AS CEO OF MOSAIC. MR. HOFFMAN SERVES AS CFO OF MOSAIC. THE SALARY FOR MS. TIMMONS IS SET BY THE MOSAIC EXECUTIVE COMMITTEE AND MOSAIC BOARD OF DIRECTORS. MR. HOFFMAN'S SALARY IS SET BY THE CEO OF MOSAIC WORKING WITHIN THE SALARY RANGES ESTABLISHED BY THE EXECUTIVE COMMITTEE. MOSAIC'S BOARD AND COMPENSATION COMMITTEE USE AN INDEPENDENT COMPENSATION CONSULTANT, A WRITTEN EMPLOYMENT CONTRACT, AND A COMPENSATION SURVEY IN ESTABLISHING THE COMPENSATION OF THE PRESIDENT AND CEO OF MOSAIC AND GUIDELINES FOR OTHER KEY STAFF. SCHEDULE J, PART II, COLUMN C: MOSAIC EVALUATES THE LIABILITY RELATED TO THEIR POSTRETIREMENT BENEFITS (SALARY AND HEALTH INSURANCE CONTINUATION) THROUGH AN ACTUARIAL REVIEW. THE ADJUSTMENT IS INCLUDED IN RETIREMENT AND OTHER DEFERRED COMPENSATION. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 AND SUPPORTING SCHEDULES ARE PROVIDED TO THE BOARD OF DIRECTORS FOR REVIEW PRIOR TO FILING. FURTHERMORE, THE FORM 990 IS REVIEWED BY THE FINANCE DEPARTMENT OF MOSAIC, A RELATED ENTITY, PRIOR TO SUBMISSION OF THE FORM 990 TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS EACH TRUSTEE COMPLETES A CONFLICT OF INTEREST FORM AND SUBMITS IT TO THE CHAIRPERSON OF THE BOARD INTEGRITY COMMITTEE. ANY FINANCIAL CONFLICTS OF INTEREST ARE REPORTED TO THE CHIEF FINANCIAL OFFICER FOR REPORTING ON THE FORM 990. ANY NEW CONFLICTS OF INTEREST THAT ARISE DURING THE YEAR ARE REQUIRED TO BE REPORTED AT THAT TIME. FORM 990, PART VI, SECTION B, LINE 15 MOSAIC EMPLOYEE WELFARE BENEFIT PLAN DOES NOT PAY COMPENSATION TO A CEO, EXECUTIVE DIRECTOR, TOP MANAGEMENT OFFICIAL, OFFICERS, OR EMPLOYEES. THEREFORE, THERE IS NOT A PROCESS IN PLACE FOR DETERMINING COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 MOSAIC EMPLOYEE WELFARE BENEFIT PLAN MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. FORM 990, PART VII CONTACT ADDRESSES FOR OFFICERS, DIRECTORS, ETC GREAT WESTERN BANK - 6015 RADIAL HWY, OMAHA, NE 68104-3425. MOSAIC 4980 S 118 STREET OMAHA NE 68137 113669999 SERVICES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES NE 501(C)(3) LINE 10 N/A 0 MOSAIC FOUNDATION 4980 S 118 STREET OMAHA NE 68137 363837360 FUNDRAISING AND INVESTMENT ASSET MANAGEMENT NE 501(C)(3) LINE 12A, I MOSAIC 1 MOSAIC HOUSING CORP I 4980 S 118 STREET OMAHA NE 68137 363756911 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP II 4980 S 118 STREET OMAHA NE 68137 470773689 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP IV 4980 S 118 STREET OMAHA NE 68137 911823422 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP VII 4980 S 118 STREET OMAHA NE 68137 470828015 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP VIII 4980 S 118 STREET OMAHA NE 68137 470828012 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP IX 4980 S 118 STREET OMAHA NE 68137 742838413 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP X 4980 S 118 STREET OMAHA NE 68137 742908789 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP XI 4980 S 118 STREET OMAHA NE 68137 311706640 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP XII 4980 S 118 STREET OMAHA NE 68137 481297244 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP XIII 4980 S 118 STREET OMAHA NE 68137 421626679 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP XIV - ROCKFORD 4980 S 118 STREET OMAHA NE 68137 204417891 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP XV - COUNCIL BLUFFS 4980 S 118 STREET OMAHA NE 68137 205765691 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP XVI - FARMINGTON 4980 S 118 STREET OMAHA NE 68137 205765731 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP XVII - BEATRICE 4980 S 118 STREET OMAHA NE 68137 261710013 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP XVIII - OSCEOLA-WAUKON 4980 S 118 STREET OMAHA NE 68137 261710184 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP XIX - WINFIELD 4980 S 118 STREET OMAHA NE 68137 261710259 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP XX - GARDEN CITY 4980 S 118 STREET OMAHA NE 68137 264555206 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP XXI - MEMPHIS 4980 S 118 STREET OMAHA NE 68137 264555313 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORP XXII - LOGAN 4980 S 118 STREET OMAHA NE 68137 273483415 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC HOUSING CORPORATION XXIII - AUSTIN 4980 S 118 STREET OMAHA NE 68137 710875364 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 THE OAKS OF DUNN COUNTY 4980 S 118 STREET OMAHA NE 68137 391913323 SENIOR LIVING SERVICES WI 501(C)(3) LINE 10 MOSAIC 1 MOSAIC ILLINOIS HOUSING I 4980 S 118 STREET OMAHA NE 68137 202997161 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC ILLINOIS HOUSING II 4980 S 118 STREET OMAHA NE 68137 204417645 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC ILLINOIS HOUSING AT MACOMB I 4980 S 118 STREET OMAHA NE 68137 204841909 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC ILLINOIS HOUSING AT ROCKFORD I 4980 S 118 STREET OMAHA NE 68137 204841856 LOW INCOME HOUSING NE 501(C)(3) LINE 10 MOSAIC 1 MOSAIC SENIOR SERVICES INC 4980 S 118 STREET OMAHA NE 68137 831746407 SENIOR LIVING SERVICES AZ 501(C)(3) LINE 12A, I MOSAIC 1 MOSAIC RESIDENTIAL SERVICES OF NEBRASKA LLC 4980 S 118 ST OMAHA NE 68137 271695051 LOW INCOME HOUSING NE N/A EASE-E MEDICAL INC 731 SOUTH 8TH STREET CANON CITY CO 81212 470842353 MEDICAL EQUIPMENT/SUPPLIES SALES NE N/A C 1 MOSAIC HOUSING CORPORATION V 4980 S 118 ST OMAHA NE 68137 470805545 LOW INCOME HOUSING NE N/A C 1 BICO 4980 S 118 ST OMAHA NE 68137 CAPTIVE INSURANCE BD N/A C 1 CHARITABLE REMAINDER TRUSTS (5) INVESTMENT MANAGEMENT NE N/A T 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0