2018-11-14T18:41:21-06:00 2017-12-31 952648289 VAVRINEK TRINE DAY & CO LLP 1900 S NORFOLK STREET SUITE 225 SAN MATEO CA 94403 990 2017-01-01 680139450 UFCW NORTHERN CALIFORNIA AND DRUG EMPLOYERS HEALTH AND WELFARE TRUST FUND UFCW 9257467530 1000 BURNETT AVENUE NO 200 CONCORD CA 94520 RICK A SILVA OFFICER 9257467530 2018-11-14 1 TROY ATKINSON P00739466 9094664410 65.60.100.226 2018-11-14 16:38:02 PS P C8485762D0A103083B9EABF22E0AFFE603142D80 A8923EACCE2D6A4F1290DCBC04922AB836540ED7 2017 2019-02-21 02:37:17Z 1000 BURNETT AVENUE NO 200 CONCORD CA 94520 21672691 0 X N/A X 1987 CA SEE PART III (4A) 8 8 0 0 0 0 0 0 21583129 20214867 58962 65891 433904 236636 22075995 20517394 0 0 23659487 22096487 0 0 0 0 0 2012125 2106677 25671612 24203164 -3595617 -3685770 9398852 5727878 6203285 6200761 3195567 -472883 NONE 0 0 TO PROVIDE HEALTH AND WELFARE BENEFITS TO EMPLOYEES AND OTHER ELIGIBLE PERSONS. 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 1 411 0 0 1 0 0 0 0 0 0 0 0 X 8 8 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 1 1 0 0 0 X JESSE GLAVES 9257467530 1000 BURNETT AVENUE CONCORD CA 94520 X BARBARA M KAY TRUSTEE 5.00 X 0 0 0 MARLA DONATI TRUSTEE 5.00 X 0 0 0 MIKE FRENNA TRUSTEE 5.00 X 0 0 0 RICK GLAZER TRUSTEE 5.00 X 0 0 0 JOHN HEISE TRUSTEE 5.00 X 0 0 0 ADAM S LOVEALL TRUSTEE 5.00 X 0 0 0 CARL NAKANO TRUSTEE 5.00 X 0 0 0 ABRAHAM BRESLIN TRUSTEE 5.00 X 0 0 0 0 0 0 0 0 0 0 UFCW ADMIN LLC 1000 BURNETT AVE 110 CONCORD CA 94520 ADMINISTRATOR 874778 BLUE SHIELD 3401 N CENTRE LAKE DR 400 ONTARIO CA 91761 ADMINISTRATOR 467583 THE SEGAL COMPANY 100 MONTGOMERY ST STE 500 SAN FRANCISCO CA 94104 ACTUARY/CONSULTANT 186611 JOHN H COHENOUR 225 WATT AVE 335 SACRAMENTO CA 95825 LEGAL 152500 4 EMPLOYER CONTRIBUTIONS 900099 19030030 19030030 PARTICIPANT CONTRIBUTIONS 900099 1184837 1184837 20214867 76188 76188 1145000 1155297 -10297 -10297 -10297 RETIREE DRUG SUBSIDY 900099 191545 191545 STOP LOSS REIMBURSEMENT 900099 45091 45091 236636 20517394 20441206 0 76188 22096487 874778 152500 51489 61566 6870 13806 HEALTHCARE ADMIN AND ME 674813 CONSULTING SERVICES 186611 UNION LOCAL ADMIN SUPPO 42368 FINANCIAL ADVISORY FEES 28125 13751 24203164 3639098 936290 4009912 3093084 1749842 1698504 9398852 5727878 21192 29408 6182093 6171353 6203285 6200761 X 0 0 0 0 3195567 -472883 3195567 -472883 9398852 5727878 -3685770 17320 0 X X 0 1 X 1 0 0 DUE TO OTHER TRUSTS 5353 CLAIMS PAYABLE AND PREMIUMS PAYABLE 3365000 CLAIMS INCURRED BY NOT REPORTED 2801000 6171353 X 20534714 17320 17320 20517394 0 20517394 24203164 0 24203164 0 24203164 PART X, LINE 2: THE TRUST HAS ADOPTED GUIDANCE ON ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES ISSUED BY THE FINANCIAL ACCOUNTING STANDARDS BOARD. THE TRUST ADMINISTRATOR BELIEVES THAT THE TRUST HAS NOT TAKEN UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENT TO THE FINANCIAL STATEMENTS AS A TAX LIABILITY. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION DELEGATES CONTROL OVER MANAGEMENT DUTIES CUSTOMARILY PERFORMED BY OR UNDER THE DIRECT SUPERVISION OF OFFICERS, DIRECTORS, TRUSTEES, OR KEY EMPLOYEES TO THE CONTRACT ADMINISTRATOR. FORM 990, PART VI, SECTION B, LINE 11B THE TRUSTEES GIVE AUTHORITY TO THE CHAIR AND SECRETARY TO REVIEW THE FORM, AND THE TRUSTEES REVIEW AFTER SUBMISSION. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON WRITTEN REQUEST. FORM 990, PART XI, LINE 2C: THE BOARD OF TRUSTEES ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE PLAN'S FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT AUDITOR. UFCW PHARMACISTS CLERKS AND DRUG EMPLOYER'S PENSION TRUST 1000 BURNETT AVE STE 200 CONCORD CA 94520 942518312 DEFINED BENEFIT PENSION PLAN CA 401(A) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 PARTS II,III, IV - IDENTIFICATION OF RELATED TAX ORGANIZATIONS IN A MULTIEMPLOYER PLAN, A CONTRIBUTING EMPLOYER IS CONSIDERED A RELATED ORGANIZATION BECAUSE THEY ARE OBLIGATED TO CONTRIBUTE TO THE PLAN PURSUANT TO THE TERMS IN THE COLLECTIVE BARGAINING OR PARTICIPATION AGREEMENT. THE ADMINISTRATIVE OFFICE ONLY MAINTAINS THE DATA NECESSARY TO FULFILL THE OBLIGATION TO CONTRIBUTE, IT DOES NOT MAINTAIN SPECIFIC BUSINESS DATA REGARDING THE EMPLOYERS, SUCH AS ENTITY TYPE OR TAX INFORMATION.