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CVI Health Care Plan: Form 990, tax year 2010

View the entire original 990 at ProPublica ↗

Organization
CVI Health Care Plan (EIN 56-1231050)
Tax period
2010-01-01 to 2010-12-31
Filed
2011-10-14
IRS object ID
201112879349300201
Schema version
2010v3.4
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2011-10-14T07:05:01-05:00Timestamp
Tax Period End Date2010-12-31TaxPeriodEndDate

Preparer Firm PreparerFirm

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1Russell L Isenhour CPA PCBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line1104 Third Street NE 100AddressLine1
CityHickoryCity
StateNCState
ZIP Code286015123ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2010-01-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN561231050EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1Century Health Care PlanBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlCENTNameControl
Phone8283268365Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line1PO Box 608AddressLine1
CityHickoryCity
StateNCState
ZIP Code28603ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameRichard ReeseName
TitleTrusteeTitle
Phone8283268365Phone
Date Signed2011-10-13DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameRussell L Isenhour CPAName
Phone8283229300Phone
Date Prepared2011-09-30DatePrepared
FieldValueIRS element (for citing)
Tax Year2010TaxYear
Build TS2016-03-07 17:11:31ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonRichard ReeseNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line1401 11th Street NWAddressLine1
CityHickoryCity
StateNCState
ZIP Code28601ZIPCode
FieldValueIRS element (for citing)
Gross Receipts11149498GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501cXOrganization501c
Web SiteN/AWebSite
Type Of Organization TrustXTypeOfOrganizationTrust
Year Formation1978YearFormation
State Legal DomicileNCStateLegalDomicile
Activity Or Mission DescriptionEMPLOYEE WELFARE BENEFIT PLANActivityOrMissionDescription
Nbr Voting Members Governing Body3NbrVotingMembersGoverningBody
Nbr Independent Voting Members0NbrIndependentVotingMembers
Total Nbr Employees0TotalNbrEmployees
Total Nbr Volunteers0TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year0ContributionsGrantsPriorYear
Contributions Grants Current Year0ContributionsGrantsCurrentYear
Program Service Revenue Prior Year9310563ProgramServiceRevenuePriorYear
Program Service Revenue CY11149498ProgramServiceRevenueCY
Investment Income Prior Year0InvestmentIncomePriorYear
Investment Income Current Year0InvestmentIncomeCurrentYear
Other Revenue Prior Year0OtherRevenuePriorYear
Other Revenue Current Year0OtherRevenueCurrentYear
Total Revenue Prior Year9310563TotalRevenuePriorYear
Total Revenue Current Year11149498TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year0GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY0GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year8715294BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY10605878BenefitsPaidToMembersCY
Salaries Etc Prior Year0SalariesEtcPriorYear
Salaries Etc Current Year0SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year595269OtherExpensePriorYear
Other Expenses Current Year543620OtherExpensesCurrentYear
Total Expenses Prior Year9310563TotalExpensesPriorYear
Total Expenses Current Year11149498TotalExpensesCurrentYear
Revenues Less Expenses Prior Year0RevenuesLessExpensesPriorYear
Revenues Less Expenses CY0RevenuesLessExpensesCY
Total Assets BOY0TotalAssetsBOY
Total Assets EOY0TotalAssetsEOY
Total Liabilities BOY0TotalLiabilitiesBOY
Total Liabilities EOY0TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY0NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY0NetAssetsOrFundBalancesEOY
Mission DescriptionTo provide sickness and accident benefits for eligible employees of C.V. Industries.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense11149498Expense
Revenue11149498Revenue
DescriptionPROVIDING HEALTH CARE BENEFITS TO APPROXIMATELY 1,200 PARTICIPANTS AND THEIR COVERED DEPENDENTSDescription
Total Program Service Expense11149498TotalProgramServiceExpense
Described In501 C30DescribedIn501C3
Schedule B Required0ScheduleBRequired
Political Activities0PoliticalActivities
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments0TermOrPermanentEndowments
Report Land Bldg Equip0ReportLandBldgEquip
Report Invest Oth Securities0ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets0ReportOtherAssets
Report Other Liabilities0ReportOtherLiabilities
Report Fin48 Footnote0ReportFin48Footnote
Independent Audit Financial Stmt1IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt0ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital0Hospital
Grants To Organizations0GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required0ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Transaction Related Entity0TransactionRelatedEntity
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With10960NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Number Of Employees0NumberOfEmployees
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members3NbrVotingGoverningBodyMembers
Number Independent Voting Members0NumberIndependentVotingMembers
Family Or Business Relationship1FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders0MembersOrStockholders
Election Of Board Members0ElectionOfBoardMembers
Decisions Subject To Approval0DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body1Form990ProvidedToGoverningBody
Conflict Of Interest Policy0ConflictOfInterestPolicy
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO0CompensationProcessCEO
Compensation Process Other0CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1ROBERT JOHNSONBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number8283251851TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1401 11th Street NWAddressLine1
CityHickoryCity
StateNCState
ZIP Code28601ZIPCode
FieldValueIRS element (for citing)
No Listed Persons CompensatedXNoListedPersonsCompensated

Form990 Part VII Section A Form990PartVIISectionA (3 entries)

TitleTitleIndividual Trustee Or DirectorIndividualTrusteeOrDirectorReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensation
L SNYDER GARRISON JR
TRUSTEEX000
RICHARD REESE
TRUSTEEX000
ROBERT JOHNSON
TRUSTEEX000
FieldValueIRS element (for citing)
Total Reportable Comp From Org0TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs0TotalReportableCompFrmRltdOrgs
Total Other Compensation0TotalOtherCompensation
Number Individuals GT100 K0NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K0TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources

Contractor Compensation ContractorCompensation (3 entries)

Address Line1AddressOfContractor/AddressUS/AddressLine1CityAddressOfContractor/AddressUS/CityStateAddressOfContractor/AddressUS/StateZIP CodeAddressOfContractor/AddressUS/ZIPCodeDescription Of ServicesDescriptionOfServicesCompensationCompensation
Sun Life Assurance Company of Canada
1001 Haxall Point Suite 708RichmondVA23219Stop Loss Agreement248423
DirectNet LLC
1333 2nd St NW Suite 200HickoryNC28601Networking Services149419
Wells Fargo Third Party Administrators
PO Box 3043CharlestonWV253313043Third Party Administrator127086
FieldValueIRS element (for citing)
Number Of Contractors GT100 K3NumberOfContractorsGT100K

Program Service Revenue ProgramServiceRevenue (4 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnRelated Or Exempt Function IncomeRelatedOrExemptFunctionIncome
EMPLOYER CONTRIBUTIONS52510081424868142486
EMPLOYEE CONTRIBUTIONS52510025910512591051
EMPLOYER RE NURSE525100391759391759
EMPLOYER RE COUNSELING5251002420224202
FieldValueIRS element (for citing)
Total Program Service Revenue11149498TotalProgramServiceRevenue

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column11149498TotalRevenueColumn
Related Or Exempt Function Income11149498RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion$0ExclusionAmount

Benefits To Members BenefitsToMembers

FieldValueIRS element (for citing)
Total10605878Total
Program Services10605878ProgramServices

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total14061Total
Program Services14061ProgramServices

Other Expenses OtherExpenses

FieldValueIRS element (for citing)
DescriptionADMINISTRATIVE FEESDescription
Total529559Total
Program Services529559ProgramServices

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total11149498Total
Program Services11149498ProgramServices
Management And General0ManagementAndGeneral
Fundraising0Fundraising

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY
FieldValueIRS element (for citing)
Do Not Follow SFAS117XDoNotFollowSFAS117

Cap Stck Trst Prin Current Funds CapStckTrstPrinCurrentFunds

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Paid In Cap Srpls Land Bldg Eqp Fund PaidInCapSrplsLandBldgEqpFund

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Retained Earnings Endowment Etc RetainedEarningsEndowmentEtc

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY
FieldValueIRS element (for citing)
Reconcilation Revenue Expenses0ReconcilationRevenueExpenses
Reconcilation Other Changes0ReconcilationOtherChanges
Info In Schedule O Part XIIXInfoInScheduleOPartXII
Method Of Accounting CashXMethodOfAccountingCash
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited
Audit Committee1AuditCommittee
Financial Statement SeparateXFinancialStatementSeparate
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule D IRS990ScheduleD

FieldValueIRS element (for citing)
Total Of Book Value Land Buildings0TotalOfBookValueLandBuildings
Total Revenue11149498TotalRevenue
Total Expenses11149498TotalExpenses
Excess Or Deficit For Year0ExcessOrDeficitForYear
Total Adjustments0TotalAdjustments
Excess Or Deficit Per FS0ExcessOrDeficitPerFS
Tot Revenue Etc Audited Fincl Stmt11149498TotRevenueEtcAuditedFinclStmt
Revenue Not Rptd F9900RevenueNotRptdF990
Revenue Subtotal11149498RevenueSubtotal
Revenue Not Rptd On Fin Stmt0RevenueNotRptdOnFinStmt
Total Revenue Per Form99011149498TotalRevenuePerForm990
Tot Expenses Etc Audited Fincl Stmt11149498TotExpensesEtcAuditedFinclStmt
Expenses Not Rptd F9900ExpensesNotRptdF990
Expenses Subtotal11149498ExpensesSubtotal
Expenses Not Rptd On Fin Stmt0ExpensesNotRptdOnFinStmt
Total Expenses Per Form99011149498TotalExpensesPerForm990

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (4 entries)

IdentifierIdentifierExplanationExplanationReturn ReferenceReturnReference
Form 990, Part VI, Section A, line 2Richard Reese, Trustee, is an officer of CV Industries, Inc., which owns the employer of Snyder Garrison, Trustee.
Form 990, Part VI, Section B, line 11A 990 draft was provided by Russell L. Isenhour, CPA, PC to the Trustees for review. After approval from the Trustees, a final 990 was assembled and delivered to the Trustees for filing.
There is not a written policy for conflict of interest. Governing documents and financial statements are available to the public upon request.Form 990, Part VI, Section C, line 19
The Trustees engaged Russell L. Isenhour, CPA, PC to audit the year ended December 31, 2010. Richard Reese, Trustee, assumes responsibility for oversight of the audit.Form 990 Part XII 2c

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII (3 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodePrimary ActivitiesPrimaryActivitiesLegal Domicile StateLegalDomicileStateExempt Code SectionExemptCodeSectionBusiness Name Line1DirectControllingEntityName/BusinessNameLine1Controlled OrgControlledOrg
Century Furniture LLC Pension Plan and Trust
401 11th St NWHickoryNC28601Defined Benefit Pension Plan (frozen 12/31/1994)NC401(a)Century FurnitureLLC0
CV Industries 401(K) Plan
401 11th St NWHickoryNC28601Defined Contribution Pension PlanNC401(a)CV Industries Inc0
CV Industries Inc Employee Stock Ownership Plan
401 11th St NWHickoryNC28601Defined Contribution Pension PlanNC401(a)CV Industries Inc0

Form990 Schedule R Part IV Form990ScheduleRPartIV

Name Of Related Org NameOfRelatedOrg

FieldValueIRS element (for citing)
Business Name Line1CV Industries IncBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1401 11th St NWAddressLine1
CityHickoryCity
StateNCState
ZIP Code28601ZIPCode
FieldValueIRS element (for citing)
EIN561043374EIN
Primary ActivityPlan SponsorPrimaryActivity
Legal Domicile StateNCLegalDomicileState
Type Of EntityCTypeOfEntity
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties0ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org0GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org0GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org0LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org0LoansOrGuaranteesFromOtherOrg
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org0PurchaseOfAssetsFromOtherOrg
Exchange Of Assets0ExchangeOfAssets
Rental Of Facilities To Other Orgs0RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs0RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs0PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs0PerformOfServicesByOtherOrgs
Sharing Of Facilities0SharingOfFacilities
Sharing Of Paid Employees0SharingOfPaidEmployees
Reimbursement Paid To Other Org0ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org0ReimbursementPaidByOtherOrg
Other Transfer To Other Org0OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg