2013-05-14T09:21:47-05:00 2012-09-30 611436956 NOVAK FRANCELLA LLC ONE PRESIDENTIAL BLVD SUITE 330 BALA CYNWYD PA 19004 990 2011-10-01 221458594 UFCW NATIONAL HEALTH AND WELFARE FUND UFCW 2015698801 66 GRAND AVENUE ENGLEWOOD NJ 07631 GEORGE J ORLANDO 2015698801 2013-05-09 LOUIS VERZELLA CPA P00360279 6106689400 2013-05-09 2011 2016-02-24 21:20:13Z X GEORGE J ORLANDO 66 GRAND AVENUE ENGLEWOOD NJ 07631 100689928 0 X N/A X 1947 NJ THE PLAN PROVIDES HOSPITAL, MAJOR MEDICAL, SURGICAL, DISABILITY, PRESCRIPTION DRUG AND DEATH BENEFITS TO ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS. ALL HEALTH, DISABILITY, PRESCRIPTION DRUG AND DEATH BENEFITS ARE SELF-FUNDED. 7 7 27 0 0 0 0 0 80435727 83049217 831586 1234939 0 0 81267313 84284156 0 0 74627331 77471317 2442454 2309691 0 0 0 1735382 1672681 78805167 81453689 2462146 2830467 32213041 34847441 0 0 32213041 34847441 THE PLAN PROVIDES HOSPITAL, MAJOR MEDICAL, SURGICAL, DISABILITY, PRESCRIPTION DRUG AND DEATH BENEFITS TO ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS. ALL HEALTH, DISABILITY, PRESCRIPTION DRUG AND DEATH BENEFITS ARE SELF-FUNDED. 0 0 THE FUND PROVIDES MEDICAL, HOSPITAL, PRESCRIPTION DRUGS AND DEATH BENEFITS FOR MEMBERS AND THEIR DEPENDENTS. 0 0 0 0 0 0 0 0 0 1 0 0 0 0 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 0 1 9 0 27 1 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X BOARD OF TRUSTEES 2015698801 66 GRAND AVENUE ENGLEWOOD NJ 07631 GEORGE J ORLANDO 1.00 X 0 0 0 TOM R BALLARD 1.00 X 0 0 0 FRANK J RUNEY 2.00 X 0 0 0 GERALDINE SENACK 1.00 X 0 0 0 MICHELLE LEWIS 1.00 X 0 0 0 JOHN PEPE 2.00 X 0 0 0 ALIA SAMAD-SALAMEH 1.00 X 0 0 0 MAURICE HODOS 40.00 X 158612 0 18533 158612 0 18533 1 0 1 0 HORIZON BLUE CROSS BLUE SHIELD 3 PENN PLAZA EAST PP-04K NEWARK NJ 07105 CLAIMS ADMINISTRATION 1686043 INFORMED LLC 1596 WHITEHALL RD ANNAPOLIS MD 21409 CLAIMS ADMINISTRATION 572550 THE SEGAL COMPANY 333 WEST 34TH STREET NEW YORK NY 10001 CONSULTING/ACTUARIAL FEES 288150 KENNEDY JENNIK & MURRAY PC 113 UNIVERSITY PLACE NEW YORK NY 10003 LEGAL SERVICES 141477 UBS FINANCIAL SERVICES INC 1285 AVENUE OF THE AMERICAS NEW YORK NY 10019 INVESTMENT MANAGEMENT 101159 5 EMPLOYER CONTRIBUTIONS 525100 82315406 82315406 PARTICIPANT AND RETIRE 525100 511071 511071 MEDICARE PART D REIMB. 525100 222740 222740 83049217 659383 659383 16981328 16405772 575556 575556 575556 84284156 83049217 0 1234939 77471317 1405194 482515 302577 119405 193460 114711 31826 498924 382727 120307 201143 78645 4113 29013 TEMPORARY STAFF AGENCY 17812 81453689 1037141 1604557 9663357 9026735 845285 837542 7898 7743 21137978 23841739 366667 366667 32213041 34847441 0 0 X 0 0 0 0 32213041 34847441 32213041 34847441 32213041 34847441 X 2830467 -196067 X X 0 1 1 X 0 2394 2394 0 231884 224591 7293 611007 610557 450 7743 84284156 81453689 2830467 -196067 -196067 2634400 86916220 2355229 2355229 84560991 139213 -416048 -276835 84284156 81526951 0 81526951 139213 -212475 -73262 81453689 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: MANAGEMENT EVALUATED THE PLAN'S TAX POSITIONS AND CONCLUDED THAT THE PLAN HAD MAINTAINED ITS TAX EXEMPT STATUS AND HAD TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENT TO THE FINANCIAL STATEMENTS. THEREFORE, NO PROVISION OR LIABILITY FOR INCOME TAXES HAS BEEN INCLUDED IN THE FINANCIAL STATEMENTS. AT THE PRESENT TIME, THE PLAN IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY U.S. FEDERAL, STATE, OR LOCAL TAX AUTHORITIES FOR YEARS BEFORE 2009. PART XI, LINE 8 - OTHER ADJUSTMENTS: ADJUSTMENT OF COST BASIS OF INVESTMENTS -196,067. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN RECEIVABLES -415,648. CHANGE IN DUE TO RETIREMENT FUND -400. PART XIII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN PAYABLES -132,128. CHANGE IN ACCRUED PENSION COST & FASB 715 ADJ -80,347. X 0 0 0 MAURICE HODOS 158612 0 0 0 0 0 9227 0 9306 0 177145 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 UFCW NATIONAL HEALTH AND WELFARE FUND'S FORM 990 IS PREPARED BY ITS INDEPENDENT ACCOUNTANT. THE RETURN IS THEN FORWARDED TO THE FUND ADMINISTRATOR FOR INITIAL REVIEW BEFORE BEING PRESENTED TO THE TRUSTEES FOR REVIEW AND SIGNATURE. FORM 990, PART VI, SECTION B, LINE 12C UFCW NATIONAL HEALTH & WELFARE FUND MONITORS ITS CONFLICT OF INTEREST POLICY ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION OF PLAN SERVICE PROVIDERS IS SUBJECT TO APPROVAL OF THE BOARD OF TRUSTEES UNDER THE PLAN'S TRUST AGREEMENTS. PERSONS WITH A CONLFICT OF INTEREST WITH RESPECT TO A COMPENSATION ARRANGEMENT WILL NOT BE INVOLVED. DATA AS TO COMPARABLE COMPENSATION FOR SIMILARLY QUALIFIED PERSONS IN FUNCTIONALY COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS IS USED. CONTEMPORANEOUS DOCUMENTATION AND REORDS AND DECISIONS REGARDING THE COMPENSATION ARRANGEMENT ARE MADE AND KEPT. FORM 990, PART VI, SECTION C, LINE 19 UFCW NATIONAL HEALTH AND WELFARE FUND MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. CONTACT ADDRESSES FOR OFFICERS, DIRECTORS, ETC FORM 990, PART VII GEORGE J. ORLANDO - 219 PATERSON AVENUE, LITTLE FALLS, NJ 07424. GERALDINE SENACK - 556 BOCA CIEGA POINT BLVD. SOUTH, MADEIRA BEACH, FL 33708. MICHELLE LEWIS - E & J GALLO WINERY, P.O. BOX 1130, MODESTO, CA 95353. JOHN PEPE - 520 DIVISION ST, GALLO WINE SALES OF NJ, ELIZABETH, NJ 07201. ALIA SAMAD-SALAMEH - P.O. BOX 600, SHAW'S SUPERMARKETS INC, E BRIDGEWATER, MA 02333. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: ADJUSTMENT OF COST BASIS OF INVESTMENTS -196,067. TOTAL TO FORM 990, PART XI, LINE 5: -196,067. FORM 990, PART XII, LINE 1: UFCW NATIONAL HEALTH AND WELFARE FUND'S FORM 990 IS PREPARED USING THE MODIFIED CASH BASIS OF ACCOUNTING. FORM 990, PART XII, LINE 2C: UFCW NATIONAL HEALTH AND WELFARE FUND'S BOARD OF TRUSTEES IS RESPONSIBLE FOR OVERSEEING THE FINANCIAL STATEMENT AUDIT AND SELECTION OF THE INDEPENDENT ACCOUNTANT THAT PERFORMS THE AUDIT. 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