2017-04-10T16:20:08-05:00 2016-05-31 131578842 BUCHBINDER TUNICK & COMPANY LLP ONE PENNSYLVANIA PLAZA SUITE 5335 NEW YORK NY 10119 990 2015-06-01 111637886 LOCAL 804 WELFARE TRUST FUND LOCA 7187865410 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 EDWEEN VILLALTA TRUSTEE 7187865410 2017-04-10 1 GREG AUTERI P01366109 2126955003 2015 2021-01-29 14:40:06Z EDWEEN VILLALTA 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 103825241 0 X HTTP://WWW.LOCAL804FUND.COM X 1950 NY TO PROVIDE HEALTH CARE BENEFITS 8 4 27 0 0 0 0 0 76299009 81624031 2040247 1360567 31728 193200 78370984 83177798 0 0 63722902 69945889 2250556 2413849 0 0 0 1579986 1908387 67553444 74268125 10817540 8909673 65922960 73079150 1551143 447121 64371817 72632029 X THE LOCAL 804 WELFARE TRUST FUND WAS CREATED IN 1950, UNDER AN AGREEMENT AND DECLARATION OF TRUST, AS AMENDED, BETWEEN DELIVERY AND WAREHOUSE EMPLOYEES UNION, LOCAL 804 IBT (THE UNION") AND VARIOUS EMPLOYERS. THE UNION AND THE EMPLOYERS HAVE ENTERED INTO COLLECTIVE BARGAINING AGREEMENTS REQUIRING PAYMENTS BY THE EMPLOYERS FOR THE PURPOSE OF ESTABLISHING A WELFARE PROGRAM FOR THE EMPLOYERS TO PROVIDE WELFARE BENEFITS FOR THEIR EMPLOYEES AND THE EMPLOYEES OF THE UNION, AND THE EMPLOYEES OF THE LOCAL 804 WELFARE TRUST FUND. 0 0 PROVIDED HEALTH CARE BENEFITS FOR ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS. ESTIMATED NUMBER OF PARTICIPANTS BENEFITED DURING THE PAST YEAR WAS 4786. 0 0 0 0 0 0 0 0 0 1 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 1 632 0 1 27 1 0 0 0 0 0 0 X 8 4 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 1 1 0 X THOMAS LAMONTANARO FUND MANAGER 7187865410 34-21 REVIEW AVENUE LONG ISLAND CITY NY 11101 TIMOTHY SYLVESTER UNION TRUSTEE (RESIGNED 12/31/15) 1.00 40.00 X 0 148399 36256 JAMES REYNOLDS UNION TRUSTEE (RESIGNED 12/31/15) 1.00 40.00 X 0 148099 36256 PETE MASTRANDREA UNION TRUSTEE (RESIGNED 12/31/15) 1.00 40.00 X 0 147079 36256 CHRIS LANGAN EMPLOYER TRUSTEE 1.00 X 0 0 0 BRIAN MCCABE EMPLOYER TRUSTEE 1.00 X 0 0 0 DAVE FENNELL UNION TRUSTEE (RESIGNED 12/31/15) 1.00 40.00 X 0 143472 36256 JIM MCGRATH EMPLOYER TRUSTEE 1.00 X 0 0 0 MATT HOFFMAN EMPLOYER TRUSTEE 1.00 X 0 0 0 EDWEEN VILLALTA UNION TRUSTEE 1.00 40.00 X 0 0 0 JOHN PICCINICH UNION TRUSTEE 1.00 40.00 X 0 0 0 DANIEL MONTALVO UNION TRUSTEE 1.00 40.00 X 0 0 0 DANIEL BETANCOURT UNION TRUSTEE 1.00 40.00 X 0 0 0 THOMAS LAMONTANARO FUND OFFICE MANAGER 34.00 6.00 X 101842 0 47442 MARC PANTELEONE BENEFIT CLAIMS ASSISTANT 61.00 X 150283 0 27090 JAMES PANTELEONE IT AND BENEFIT CLAIMS ASSI 64.00 X 136430 0 26993 MAGGIE WU ACCOUNTANT 38.00 11.00 X 120251 0 27121 508806 587049 273670 4 0 1 0 EMPIRE HEALTHCHOICE ASSURANCE INC 1351 WM HOWARD TAFT ROAD CINCINNATI OH 45206 BENEFIT ADMINISTRATIVE SERVICE 1723281 HEALTH PLAN SYSTEM 2025 LINCOLN HIGHWAY ROUTE 21 EDISON NJ 08817 BENEFIT INFORMATION TECHNOLOGY 456849 NEW YORK MEDICAL MANAGEMENT 2025 LINCOLN HIGHWAY ROUTE 21 EDISON NJ 08817 BENEFIT CONSULTING SERVICES 399561 COHEN WEISS AND SIMON LLP 330 WEST 42ND STREET NEW YORK NY 10036 LEGAL SERVICES 307590 PROSKAUER ROSE LLP ELEVEN TIMES SQUARE NEW YORK NY 10038 LEGAL SERVICES 277383 8 CONTRIBUTIONS - EMPLOYERS 900099 78750594 78750594 CONTRIBUTIONS - RETIRED PARTICIPA 900099 2749856 2749856 CONTRIBUTIONS - COBRA PARTICIPANT 900099 123581 123581 81624031 1127479 1127479 20880531 20647443 233088 233088 233088 MISCELLANEOUS INCOME 900099 193200 193200 193200 83177798 81817231 0 1360567 69945889 147442 1504697 198991 435018 127701 634564 39000 179932 254085 202273 503894 92874 1716 220508 27506 MISC 827 DUES AND SUBSCRIPTIONS 484 ADM.EXPENSES REIMBURSED -249276 74268125 1059253 1821943 5927783 6152005 8094550 7759543 79154 107429 3221640 2772634 669514 449006 50092706 56789224 65922960 73079150 1195543 116108 207151 187664 148449 143349 1551143 447121 X 0 0 0 0 64371817 72632029 64371817 72632029 65922960 73079150 8909673 -649461 0 X 0 1 X 0 0 326292 324301 1991 746200 593517 152683 2149148 1854816 294332 449006 EST'D FUTURE RETIREMENT BENEFIT 143349 143349 X 82348405 -649461 -649461 82997866 179932 179932 83177798 74088193 0 74088193 179932 179932 74268125 PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA 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 POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE. THE PLAN ADMINISTRATOR HAS ANALYZED THE TAX POSITIONS TAKEN BY THE PLAN, AND HAS CONCLUDED THAT AS OF MAY 31, 2016, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY (OR ASSET) OR DISCLOSURE IN THE FINANCIAL STATEMENTS. EMPLOYEE BENEFIT PLANS ARE SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS FOR THE PLAN. THE PLAN ADMINISTRATOR BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO MAY 31, 2013. 0 0 0 TIMOTHY SYLVESTER UNION TRUSTEE (RESIGNED 12/31/15) 0 148399 0 0 0 0 0 25479 0 10777 0 184655 0 0 JAMES REYNOLDS UNION TRUSTEE (RESIGNED 12/31/15) 0 148099 0 0 0 0 0 25479 0 10777 0 184355 0 0 PETE MASTRANDREA UNION TRUSTEE (RESIGNED 12/31/15) 0 147079 0 0 0 0 0 25479 0 10777 0 183335 0 0 DAVE FENNELL UNION TRUSTEE (RESIGNED 12/31/15) 0 143472 0 0 0 0 0 25479 0 10777 0 179728 0 0 MARC PANTELEONE BENEFIT CLAIMS ASSISTANT 150283 0 0 0 0 0 7982 0 19108 0 177373 0 0 0 JAMES PANTELEONE IT AND BENEFIT CLAIMS ASSI 136430 0 0 0 0 0 7982 0 19011 0 163423 0 0 0 FORM 990, PART VI, SECTION A, LINE 8B THE FUND DOES NOT HAVE ANY COMMITTEE WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 THE FUND'S BOARD OF TRUSTEES REVIEWS THE FORM 990 PRIOR TO ITS FILING. FORM 990, PART VI, SECTION B, LINE 15 THE FUND'S BOARD OF TRUSTEES REVIEWS AND AUTHORIZES COMPENSATION FOR ALL EMPLOYEES, INCLUDING FOR THE TOP MANAGEMENT OFFICIAL. THE REVIEW PROCESS IS CONDUCTED AT THE BOARD MEETING AND DOCUMENTED ACCORDINGLY. FORM 990, PART VI, SECTION C, LINE 19 THE FUND MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON RECEIPT OF A PARTICIPANT'S WRITTEN REQUEST. LOCAL 804 ANNUITY FUND 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 112506358 SHARED ADMINISTRATIVE COST NY 1.401-1(B)(3) 0 LOCAL 804 IBT 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 111603598 CONTRIBUTING EMPLOYER & RENTAL EXPENSE NY 501(C)(5) 0 LOCAL 804 FEDERAL CREDIT UNION 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 112491081 CONTRIBUTING EMPLOYER NY 501(C)(1) 0 LOCAL 804 PENSION FUND 34-21 REVIEW AVENUE LONG ISLAND CITY NY 111013241 116077200 SHARED ADMINISTRATIVE COST NY 1.401-1(B)(3) 0 UNITED PARCEL SERVICE CONTRIBUTING EMPLOYER 0 EPPENDORF INC CONTRIBUTING EMPLOYER 0 TRUMP VILLAGE INC CONTRIBUTING EMPLOYER 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 LOCAL 804 ANNUITY FUND N 73959 SHARED ADM. COST AGREEMENT LOCAL 804 ANNUITY FUND O 102837 SHARED ADM. COST AGREEMENT LOCAL 804 IBT K 58005 OFFICE RENTAL EXPENSE