2018-04-11T15:42:52-05:00 2017-05-31 522385296 LINDQUIST LLP 5000 EXECUTIVE PARKWAY SUITE 400 SAN RAMON CA 94583 990 2016-06-01 910590441 HOTEL EMPLOYEES RESTAURANT EMPLOYEES HEALTH TRUST PLAN HOTE 2064417574 7525 SE 24TH STREET NO 200 MERCER ISLAND WA 98040 ENRIQUE FERNANDEZ TRUSTEE 2064417574 2018-04-11 1 TODD M STOKES P01451940 9252779100 66.7.226.66 2018-04-11 13:42:39 PD P AF0F784E429982BC93A0FAF5EDF9664BBECC31B5 AF0F784E429982BC93A0FAF5EDF9664BBECC31B5 2016 2021-01-29 14:40:06Z X ERIK VAN ROSSUM 7525 SE 24TH ST SUITE 200 MERCER ISLAND WA 98040 111247304 0 X N/A X 1976 WA TO PROVIDE HEALTH AND WELFARE BENEFITS TO ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS 9 2 145 0 0 0 0 0 36727402 36085578 1256753 2094663 107161 23222 38091316 38203463 0 0 30763947 28603599 0 0 0 0 0 2285505 2413517 33049452 31017116 5041864 7186347 67753592 77182860 9605475 10908054 58148117 66274806 TO PROVIDE HEALTH AND WELFARE BENEFITS TO ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS 0 0 PROVIDED HEALTH AND WELFARE BENEFITS TO ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS. 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 X 1209 0 1 145 1 0 0 0 0 0 0 X 9 2 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X WELFARE & PENSION ADMIN SERVICE 2064417574 7525 SE 24TH ST SUITE 200 MERCER ISLAND WA 98040 X ERIK VAN ROSSUM TRUSTEE - CHAIRMAN 0.50 X 0 0 0 HOWARD COHEN TRUSTEE - SECRETARY 0.50 X 0 0 0 SARAH WARREN TRUSTEE 0.50 X 0 0 0 LEE KAUFMAN TRUSTEE 0.50 X 0 0 0 DOUG RIGONI TRUSTEE 0.50 X 0 0 0 ENRIQUE FERNANDEZ TRUSTEE 0.50 X 0 0 0 STEFAN MORITZ TRUSTEE 0.50 X 0 0 0 DAVID GLASER TRUSTEE 0.50 X 0 0 0 NORMAN HWA TRUSTEE 0.50 X 0 0 0 SEE SCHEDULE O FOR COMPENSATION PAID BY RELATED ORGANIZATION 0.00 X 0 1 0 0 1 0 0 0 0 0 WELFARE & PENSION ADMINISTRATION SERVICE 7525 SE 24TH ST SUITE 200 MERCER ISLAND WA 98040 ADMINISTRATION 1329680 FIRST CHOICE HEALTH NETWORK INC 600 UNIVERISTY ST STE 1400 SEATTLE WA 98101 ADMINISTRATION 236212 2 EMPLOYER CONTRIBUTIONS 900099 35292167 35292167 STOP LOSS INCOME 900099 422234 422234 FORMULARY REBATES 900099 254761 254761 PARTICIPANT CONTRIBUTIONS 900099 116416 116416 36085578 1995194 1995194 73143310 73043841 99469 99469 99469 PERFORMANCE GUARANTEE 900099 11622 11622 ARBITRATION INCOME 900099 11600 11600 23222 38203463 36108800 0 2094663 28603599 1242152 36550 49830 38063 771965 155262 8291 15634 ACA TRANS. REINSURANCE 82448 PCORI FEE 13322 31017116 767238 908569 6987685 8495219 3703916 3602451 117491 4150 56177262 64172471 67753592 77182860 159431 66792 9446044 10841262 9605475 10908054 X 0 0 0 0 58148117 66274806 58148117 66274806 67753592 77182860 7186347 940342 0 X X 0 1 X 1 0 0 ACCUMULATED ELIGIBILITY CREDITS 4762000 CLAIMS PAYABLE AND INCURRED BUT NOT REPORTED 6079262 10841262 X 39105742 940342 940342 38165400 38063 38063 38203463 29583835 0 29583835 38063 1395218 1433281 31017116 PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE THE TAX POSITIONS TAKEN BY THE PLAN AND TO RECOGNIZE A TAX LIABILITY IF THE PLAN HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE PLAN AND HAS CONCLUDED THAT, AS OF MAY 31, 2017, 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. MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR THE YEARS PRIOR TO 2014. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN BENEFIT OBLIGATIONS FORM 990, PART V, LINE 2A THE TRUST DOES NOT HAVE EMPLOYEES. HOWEVER, THE TRUST ISSUED FORMS W-2 TO PARTICIPANTS THAT RECEIVED TAXABLE DISABILITY BENEFITS. FORM 990, PART VI, SECTION A, LINE 3 THE PLAN HAS CONTRACTED WITH WELFARE & PENSION ADMINISTRATION SERVICE, INC. TO PROVIDE ADMINISTRATIVE SERVICES FOR THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11B A TRUSTEE REVIEWED THE FORM 990 FOR ACCURACY AND COMPLETENESS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT-OF-INTEREST POLICY COVERS TRUSTEES (THE GOVERNING BODY). IF AND WHEN A POTENTIAL CONFLICT OF INTEREST IS DISCLOSED, THE BOARD OF TRUSTEES WILL INVOLVE THE TRUST'S ATTORNEY TO EVALUATE IF THE MATTER WOULD LIKELY PREVENT AN UNBIASED OR OBJECTIVE DECISION BY A TRUSTEE, AND AS APPROPRIATE, DISCIPLINARY OR CORRECTIVE ACTION WILL BE TAKEN. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. FORM 990, PART VII, SECTION A, LINE 1A: TRUSTEES ARE NOT COMPENSATED BY THE TRUST. COMPENSATION PAID TO TRUSTEES EMPLOYED BY OTHER RELATED ORGANIZATION IS REPORTED ON THE FORM 990 FILED WITH THE INTERNAL REVENUE SERVICE BY THE RELATED TAX-EXEMPT ORGANIZATION. IF YOU WOULD LIKE ADDITIONAL INFORMATION, PLEASE CONTACT THE THIRD-PARTY ADMINISTRATOR, WELFARE & PENSION ADMINISTRATION SERVICE, INC. FORM 990, PART XII, LINE 2C: THE BOARD OF TRUSTEES ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF INDEPENDENT AUDITORS. THIS PROCESS HAS NOT CHANGED. UNITEHERE NORTHWEST PENSION TRUST FUND PO BOX 34203 SEATTLE WA 981241203 916145131 PROVIDE PENSION BENEFITS FOR ELIGIBLE EMPLOYEES WA 501(A) N/A N/A 0 UNITE HERE LOCAL 8 2800 FIRST AVENUE ROOM 3 SEATTLE WA 98121 910968179 LABOR ORGANIZATION WA 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 ORGANIZATION THE FILING ORGANIZATION IS A TAFT-HARTLEY MULTIEMPLOYER TRUST THAT PROVIDES HEALTH AND WELFARE BENEFITS TO ELIGIBLE EMPLOYEES AND THEIR DEPENDENTS. AS OF MAY 31, 2017, THERE ARE APPROPXIMATELY 31 EMPLOYERS THAT CONTRIBUTE TO THE TRUST. THE ADMINISTRATIVE OFFICE MAINTAINS A DATABASE OF THESE CONTRIBUTING EMPLOYERS, INCLUDING NAMES, ADDRESSES AND OTHER CONTACT INFOMRATION. THE FEDERAL TAX CLASSIFICATION (DISREGARDED ENTITY, TAX EXEMPT ORGANIZATION, PARTNERSHIP, TAXABLE CORPORATION OR TRUST) FOR EACH CONTRIBUTING EMPLOYER IS NOT ON FILE WITH THE ADMINISTRATIVE 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. 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