Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 3 | THE GOVERNING BODY HAS APPOINTED MANAGEMENT DUTIES TO A THIRD-PARTY ADMINISTRATOR. |
| FORM 990, PART VI, SECTION A, LINE 8B | THE PLAN DOES NOT HAVE A COMMITTEE WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. |
| FORM 990, PART VI, SECTION B, LINE 11 | A COPY OF THE FORM 990 WAS PROVIDED TO THE BOARD OF TRUSTEES FOR REVIEW BEFORE IT WAS FILED. |
| FORM 990, PART VI, SECTION B, LINE 12C | TRUSTEES AND OTHER INDIVIDUALS SUBJECT TO THE CONFLICT-OF-INTEREST POLICY WILL BE ASKED TO DISCLOSE IN WRITING ANY RELATIONSHIPS OR INTERESTS THAT COULD GIVE RISE TO A CONFLICT, AT LEAST ONCE ANNUALLY. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE ORGANIZATION DOES NOT COMPENSATE TRUSTEES. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, FINANCIAL INFORMATION AND CONFLICT-OF-INTEREST POLICY AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART XII, LINE 2C | THE ORGANIZATION HAS NOT CHANGED EITHER ITS OVERSIGHT PROCESS OR SELECTION PROCESS DURING THE TAX YEAR. |
| FORM 990, PART VII, SECTION A, LINE 1A: | TRUSTEES ARE NOT COMPENSATED BY THE TRUST. COMPENSATION PAID TO TRUSTEES IF EMPLOYED BY OTHER RELATED ORGANIZATIONS IS REPORTED ON THE FORM 990 FILED WITH THE INTERNAL REVENUE SERVICE BY THE RELATED TAX-EXEMPT ORGANIZATION. IF YOU WOULD LIKE ADDITIONAL INFORMATION, PLEASE CONTACT THE THIRD PARTY ADMINISTRATOR, HEALTH SERVCIES BENEFIT ADMINISTRATORS, INC. |
| Software ID: | |
| Software Version: |