2017-09-08T15:16:29-05:00 2016-12-31 522385296 LINDQUIST LLP 5000 EXECUTIVE PARKWAY SUITE 400 SAN RAMON CA 94583 990 2016-01-01 776113549 NORTHERN CALIFORNIA SHEET METAL WORKERS HEALTH CARE PLAN NORT 9252089994 PO BOX 1677 SAN RAMON CA 94583 DENNIS CANEVARI TRUSTEE 9252089994 2017-09-08 1 JESSICA R ROSTER P01317380 9252779100 66.7.226.66 2017-09-08 13:16:20 PD P 72DCDAB48BBD05C01ADC32EAF6F951C821B03640 6DD8E3D40C39F05221E97E07BD1CB8F36D910CAE 2016 2021-01-29 14:40:06Z DENNIS CANEVARI PO BOX 1677 SAN RAMON CA 94583 23444764 0 X N/A X 1995 CA TO PROVIDE HEALTH AND WELFARE BENEFITS. 8 0 0 0 0 0 0 0 22425851 23078160 1646973 366604 0 0 24072824 23444764 0 0 21120380 20723949 0 0 0 0 0 1529175 1506826 22649555 22230775 1423269 1213989 22505871 23773376 8928214 8688032 13577657 15085344 TO PROVIDE HEALTH AND WELFARE BENEFITS 0 0 PROVIDED HEALTH AND WELFARE BENEFITS TO ELIGIBLE PARTICIPANTS COVERED UNDER THE COLLECTIVE BARGAINING AGREEMENTS BETWEEN THE UNION AND EMPLOYERS. 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 1 277 0 1 0 0 0 0 0 0 0 X 8 0 0 1 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 0 0 0 X BENESYS INC 9252089994 2610 CROW CANYON ROAD SUITE 200 SAN RAMON CA 94583 X SAL ROTOLO TRUSTEE 2.00 X 0 0 0 RICK WERNER TRUSTEE 2.00 X 0 0 0 DENNIS CANEVARI TRUSTEE 2.00 X 0 0 0 JIM CONWAY TRUSTEE 2.00 X 0 0 0 MIKE LOPEZ TRUSTEE 2.00 X 0 0 0 DAVID LAWSON TRUSTEE - PAST 2.00 X 0 0 0 DUSTIN SACCONE TRUSTEE 2.00 X 0 0 0 ROB BELL TRUSTEE 2.00 X 0 0 0 RICHARD COOKE TRUSTEE 2.00 X 0 0 0 SEE SCHEDULE O FOR COMPENSATION PAID BY RELATED ORGANIZATIONS 0.00 X 0 1 0 0 1 0 0 0 0 0 BENESYS INC 2610 CROW CANYON ROAD SAN RAMON CA 945831768 CONTRACT ADMINISTRATOR 832866 BLUE SHIELD 50 BEALE STREET 20TH FLOOR SAN FRANCISCO CA 94105 COST CONTAINMENT 226443 2 EMPLOYER CONTRIBUTIONS 999999 18744443 18744443 PARTICIPANT CONTRIBUTIONS 999999 4124702 4124702 MEDICARE-D REBATE 999999 156427 156427 OTHER 999999 52588 52588 23078160 366604 366604 23444764 23078160 0 366604 20723949 832866 33187 21083 28283 482743 52352 3350 12500 TRANSITIONAL INSURANCE 40462 22230775 -90132 -91608 2610303 2179305 3685927 3555586 11279 14205 16288494 18115888 22505871 23773376 168484 133213 342730 353819 8417000 8201000 8928214 8688032 X 0 0 0 0 13577657 15085344 13577657 15085344 22505871 23773376 1213989 293698 0 X X 0 1 X 1 0 0 ACCUMULATED ELIGIBILITY 6245000 CLAIMS PAYABLE AND INCURRED BUT NOT REPORTED 1956000 8201000 X 23710179 293698 293698 23416481 28283 28283 23444764 22418492 0 22418492 28283 -216000 -187717 22230775 PART X, LINE 2: THE PLAN'S ADMINISTRATOR HAS ANALYZED THE TAX POSITIONS TAKEN BY THE PLAN AND HAS CONCLUDED THAT, AS OF DECEMBER 31, 2016, 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. THE PLAN'S ADMINISTRATOR BELIEVES THE PLAN IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR THE FISCAL YEARS PRIOR TO 2013. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN BENEFIT OBLIGATIONS FORM 990, PART VI, SECTION A, LINE 3 THE TRUST HAS CONTRACTED WITH BENESYS, INC. TO PROVIDE ADMINISTRATIVE SERVICES FOR THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE A COMMITTEE WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF THE FORM 990 WAS PROVIDED TO EACH GOVERNING BODY MEMBER. REVIEW OF FORM 990 WAS CONDUCTED BY THE BOARD OF TRUSTEES (THE GOVERNING BOARD) PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, TRUSTEES ARE REQUIRED TO DISCLOSE IN WRITING ANY RELATIONSHIPS OR INTEREST THAT COULD GIVE RISE TO A CONFLICT. IF THERE IS A CONFLICT OF INTEREST, THE CONFLICTING INTEREST IS FULLY DISCLOSED AND DOCUMENTED IN WRITING; THE TRUSTEE OR FIDUCIARY WITH THE CONFLICT OF INTEREST IS EXCLUDED FROM THE DISCUSSION AND APPROVAL OF SUCH TRANSACTION; AND APPROVAL OF SUCH TRANSACTION IS DEPENDENT ON THE TRUSTEES DETERMINING THAT THE TRANSACTION IS IN THE BEST INTEREST OF THE TRUST AND THE TERMS OF THE TRANSACTION ARE FAIR WITH RESPECT TO TERMS AVAILABLE THROUGH ARMS-LENGTH TRANSACTIONS IN THE MARKETPLACE. FORM 990, PART VI, SECTION B, LINE 15 THE PLAN'S TRUSTEES ARE NOT PAID FOR THEIR SERVICES TO THE PLAN. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT-OF-INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. PART VII, SECTION A, LINE 1A TRUSTEES ARE NOT COMPENSATED BY THE TRUST. COMPENSATION PAID TO TRUSTEES EMPLOYED BY OTHER RELATED ORGANIZATIONS IS REPORTED ON THE FORM 990 FILED WITH THE INTERNAL REVENUE SERIVCE BY THE RELATED TAX-EXEMPT ORGANIZATION. IF YOU WOULD LIKE ADDITIONAL INFORMATION, PLEASE CONTACT THE THIRD-PARTY ADMINISTRATOR, BENESYS, INC. FORM 990, PART XII, LINE 2C: THE BOARD OF TRUSTEES ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT AUDITOR. THIS PROCESS HAS NOT CHANGED. SHEET METAL WORKERS LOCAL 162 DC RETIREMENT PLAN PO BOX 1677 SAN RAMON CA 94583 776138076 TO PROVIDE PENSION BENEFITS CA 501(A) N/A N/A 0 SHEET METAL WORKERS LOCAL UNION NO 104 2610 CROWN CANYON ROAD SAN RAMON CA 94583 940859420 LABOR UNION CA 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 ORGANIZATIONS: THE FILING ORGANIZATION IS A TAFT-HARTLEY MULTIEMPLOYER TRUST THAT PROVIDES HEALTH AND WELFARE BENEFITS TO ELIGIBLE EMPLOYEES AND THEIR DEPENDENTS. AS OF DECEMBER 31, 2016, THERE ARE APPROXIMATELY 93 EMPLOYERS THAT CONTRIBUTE TO THE TRUST. THE ADMINISTRATIVE OFFICE MAINTAINS A DATABASE OF THESE CONTRIBUTING EMPLOYERS, INCLUDING NAMES, ADDRESSES, AND OTHER CONTACT INFORMATION. THE FEDERAL TAX CLASSIFICATION (DISREGARDED ENTITY, TAX-EXEMPT ORGANIZATION, PARTNERSHIP, TAXABLE CORPORATION, OR TRUST) FOR EACH CONTRIBUTING EMPLOYER IS NOT ON FILE WITH THE ADMINISTRAIVE 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. 3 IN 1 CONTROL, INC. AARON HAYS INSTALLATION ABLE HEATING & A/C INC. ABM BUILDING SOLUTIONS, ACCO ENGINEERED SYSTEMS AIR CONDITIONING CO AIR CONTROL BAL., INC. AIR SYSTEMS OF SACRAMEN AIR SYSTEMS, INC. AIRCO MECHANICAL INC. ATS PRODUCTS INC B N MECHANICAL INC BEST CONTRACTING SERVIC BONESO BROTHERS CONSTRU BOS SHEET METAL BOTELHO WELDING SERVICE BRICE MECH. CONTRACTORS BROWN S/M & MECHANICAL CA DEPT PRISON-CDCR REG CAL SHEET METAL CAL-AIR COND SERVICE CAPITAL SHEET METAL WRK CENTER PLUMBING CO CHAMPION INDUSTRIAL CON CIRCO SYST BALANCE INC CLIMATE CONTROL, INC. COMFORT AIR INC CRITCHFIELD MECHANICAL CULINARY STAINLESS FABR DDK MECHANICAL DEPT OF CORRECTIONS DGS GENERAL SERVICES DKM HEATING & A/C, INC. DUCTMATE IND INC EFFICIENT ENRGY CONCPT EMCOR ARC SERVICE FINAL AIR BALANCE FLEET HEATING & AIR, IN FRANK M BOOTH FRED L HILL GENESIS MECHANICAL DESI INDOOR ENVIRONMENTAL INTECH MECHANICAL CO J H SIMPSON CO JAMES LONG CONSTRUCTION JARRELL MECHANICAL CONT KINETIC SYSTEMS INC KITCOR CORPORATION LAWSON MECHANICAL CONTR LYLES MECHANICAL COMPAN M.E.S.A. MCCLELLAND AIR CONDITIO MINA METALS MONTAGUE COMPANY MORRIS SHEET METAL MTECH CORP. NATIONAL AIR BALANCE NEW ENGLAND S/M WORKS NICRO INC NIECO CORPORATION NOLL MANUFACTURING CO NOR-CAL MTL FABRICATRS O E S S/M & FAB PACIFIC METAL FABRICATO PACIFIC TEST & BALANCE, PAN-PACIFIC MECHANICAL PATTON SHEET METAL WORK PINASCO INC R.B. SPENCER, INC. RAGLEN SYSTEM ANALYSIS RAGLEN SYSTEM BALANCE RAM MECHANICAL, INC. S/M IND JOINT APP COMM SACTO VALLEY APPR FUND SHEET METAL WORKERS 104 SHEET METAL WRKS LU 162 SHEPHARD MECH CONTR SIMPSON STRONG-TIE INC SMITH HEATING AIR COND SOLDATE S/M HEATING & A STARACE MECHANICAL STRATEGIC MECH, INC. SUPERIOR AIR HANDLING T.A.B.C.O. TERMINAL MANUFACTURING TIM HULSEY TOP NOTCH MECHANICAL, I TOWN & COUNTRY HEATING VIC MYERS SHEET METAL W A CALL MFG CO W V ALTON INC WAGNER MECHANICAL WELLMADE PRODUCTS