Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| PART I, LINE 1 AND PART III, LINES 1 AND 4A - ORGANIZATION'S MISSION: | TO PROVIDE HEALTH BENEFITS TO ELIGIBLE ACTIVE PARTICIPANTS AND THEIR COVERED DEPENDENTS. THE PLAN ALSO PROVIDES HEALTH BENEFITS TO SELF-PAY PARTICIPANTS AND RETIREES FOR WHICH A CONTRIBUTION IS RECEIVED. PART VI, LINE 2: TRUSTEES RODGER M. GLOS AND DEREK GLOS ARE FATHER AND SON. PART VI, LINE 11B: FORM 990 WAS REVIEWED BY THE ADMINISTRATIVE OFFICE PRIOR TO BEING FILED. THE ADMINISTRATIVE OFFICE WILL NOTIFY THE BOARD OF TRUSTEES OF UNUSUAL OR SIGNIFICANT ITEMS, IF NOTED. PART VI, LINE 12C: TRUSTEES ARE REQUIRED TO NOTIFY THE TRUST OF ANY CHANGES IN THEIR INTEREST THAT COULD GIVE RISE TO CONFLICTS. PART VI, LINE 19: THE PLAN'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MAINTAINED AT THE ADMINISTRATIVE OFFICE AND ARE AVAILABLE UPON REQUEST. PART VII - SECTION A: SALARIES PAID TO TRUSTEES BY THEIR NON-PROFIT EMPLOYERS IS PROPERLY REPORTED ON THE EMPLOYER'S ANNUAL PAYROLL TAX FILINGS AND THEREFORE, NOT REPORTED OR KNOWN TO THE ADMINISTRATIVE OFFICE. |
| Software ID: | |
| Software Version: |