Form990-EZ
Click to see list of attachments
Department of the Treasury
Internal Revenue Service
Short Form
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private
foundations)
bullet Do not enter social security numbers on this form as it may be made public.
bullet Information about Form 990-EZ and its instructions is at www.irs.gov/form990.
OMB No. 1545-1150
2014
Open to Public
Inspection
A
For the 2014 calendar year, or tax year beginning 07-01-2014, and ending 09-01-2014
B
Check if applicable:
C Name of organization
Insulators Local 112 Health and Welfare Fund
 
Number and street (or P. O. box, if mail is not delivered to street address)2126 Oak Park Blvd
  Room/suite
City or town, state or province, country, and ZIP or foreign postal code Lake Charles, LA70601
D Employer identification number

72-6035885
E Telephone number

(337) 474-2298
F Group Exemption
Numberbullet  
G Accounting Method: Other (specify) bullet   H Check bulletI Website:bulletN/AJ Tax-exempt status(check only one) - ( 9) bullet(insert no.) or
K Form of organization:  
L Add lines 5b, 6c, and 7b to line 9 to determine gross receipts. If gross receipts are $200,000 or more, or if total assets (Part II, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ . . . . . . . . . bullet $ 85,818
Part I
Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part I)Check if the organization used Schedule O to respond to any question in this Part I..................
VerticalRevenue 1 Contributions, gifts, grants, and similar amounts received............... 1  
2 Program service revenue including government fees and contracts ............ 2 13,858
3 Membership dues and assessments...................... 3  
4 Investment income........................... 4 6,328
5a Gross amount from sale of assets other than inventory........ 5a  
b Less: cost or other basis and sales expenses........... 5b  
c Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) ...... 5c  
6 Gaming and fundraising events
a Gross income from gaming (attach Schedule G if greater than $15,000) . 6a  
b Gross income from fundraising events (not including $   of contributions
from fundraising events reported on line 1) (attach Schedule G if the
sum of such gross income and contributions exceeds $15,000) 6b  
c Less: direct expenses from gaming and fundraising events....... 6c  
d Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract line 6c) 6d  
7a Gross sales of inventory, less returns and allowances........ 7a  
b Less: cost of goods sold................. 7b  
c Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) ......... 7c  
8 Other revenue (describe in Schedule O) ..................... 8 65,632
9 Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8.............. Bullet 9 85,818
VerticalExpenses 10 Grants and similar amounts paid (list in Schedule O) ................. 10  
11 Benefits paid to or for members........................ 11 17,869
12 Salaries, other compensation, and employee benefits................ 12  
13 Professional fees and other payments to independent contractors............ 13 685
14 Occupancy, rent, utilities, and maintenance................... 14  
15 Printing, publications, postage, and shipping................... 15 323
16 Other expenses (describe in Schedule O) .................... 16 602,701
17 Total expenses. Add lines 10 through 16 ................. Bullet 17 621,578
VerticalNetAssets 18 Excess or (deficit) for the year (Subtract line 17 from line 9)............ 18 -535,760
19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with
end-of-year figure reported on prior year’s return)................ 19 535,760
20 Other changes in net assets or fund balances (explain in Schedule O) .......... 20 0
21 Net assets or fund balances at end of year. Combine lines 18 through 20.........Bullet 21 0
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 10642I Form 990-EZ (2014)
Form 990-EZ (2014)
Page 2
Part IIBalance Sheets (see the instructions for Part II)Check if the organization used Schedule O to respond to any question in this Part II.................

(A) Beginning of year(B) End of year
22Cash, savings, and investments................
593,619
22
0
23Land and buildings....................
 
23
 
24Other assets (describe in Schedule O) ..........
15,979
24
0
25Total assets......................
609,598
25
0
26
Total liabilities (describe in Schedule O) .............
73,838
26
0
27Net assets or fund balances (line 27 of column (B) must agree with line 21)..
535,760
27
0
Part IIIStatement of Program Service Accomplishments (see the instructions for Part III) Check if the organization used Schedule O to respond to any question in this Part III . Expenses
(Required for section 501(c)(3) and 501(c)(4) organizations; optional for others.)
What is the organization's primary exempt purpose? Provide health and welfare benefits to eligible participants and their dependents.
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title.
28 Provide health and welfare benefits to eligible participants and their dependents.
(Grants $ 0) If this amount includes foreign grants, check here ...MediumBullet		 28a 0
29
(Grants $   ) If this amount includes foreign grants, check here ...MediumBullet 		29a
30
(Grants $   ) If this amount includes foreign grants, check here ...MediumBullet 		30a
31 Other program services (describe in Schedule O)
(Grants $   ) If this amount includes foreign grants, check here...MediumBullet		 31a
32 Total program service expenses (add lines 28a through 31a).......... bullet 32  
Part IV
List of Officers, Directors, Trustees, and Key Employees (list each one even if not compensated — see the instructions for Part IV)Check if the organization used Schedule O to respond to any question in this Part IV............
(a) Name and title (b) Average
hours per week
devoted to position		 (c)Reportable compensation
(Forms W-2/1099-MISC) (if not paid, enter -0-) 		(d) Health benefits, contributions to employee benefit plans,
and deferred compensation		 (e) Estimated amount
of other compensation
Lucien Clark  
Chairman 		1.00 0 0 0
Kevin Smith  
Secretary 		1.00 0 0 0
Toby Landry  
Trustee 		1.00 0 0 0
Form 990-EZ (2014)
Form 990-EZ (2014)
Page 3
Part V
Other Information
(Note the Schedule A and personal benefit contract statement requirements in the
instructions for Part V.) Check if the organization used Schedule O to respond to any question in this Part V.......
Yes
No
33
Did the organization engage in any significant activity not previously reported to the IRS? If "Yes," provide a detailed description of each activity in Schedule O ...................
33
 
No
34
Were any significant changes made to the organizing or governing documents? If "Yes," attach a conformed copy of the amended documents if they reflect a change to the organization’s name. Otherwise, explain the changeon Schedule O (see instructions) ..........................
34
 
No
35a
Did the organization have unrelated business gross income of $1,000 or more during the year from business activities (such as those reported on lines 2, 6a, and 7a, among others)? ............
35a
 
No
b
If "Yes," to line 35a, has the organization filed a Form 990-T for the year? If "No," provide an explanation in Schedule O
35b
 
 
c
Was the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice, reporting, and proxy tax requirements during the year? If "Yes," complete Schedule C, Part III
35c
 
No
36
Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets during the year? If “Yes," complete applicable parts of Schedule N Click to see attachment................
36
Yes
 
37a
Enter amount of political expenditures, direct or indirect, as described in the instructions. bullet
37a
0
b
Did the organization file Form 1120-POL for this year?...................
37b
 
 
38a
Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were
any such loans made in a prior year and still outstanding at the end of the tax year covered by this return?..
38a
 
No
b
If “Yes," complete Schedule L, Part II and enter the total amount involved .
38b
 
39
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on line 9.......
39a
 
b
Gross receipts, included on line 9, for public use of club facilities.....
39b
 
40a
Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under:
section 4911 bullet   ; section 4912 bullet   ; section 4955 bullet  
b
Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in any section 4958 excess benefit transaction during the year, or did it engage in an excess benefit transaction in a prior year that has not been reported on any of its prior Forms 990 or 990-EZ? If “Yes," complete Schedule L, Part I
40b
 
 
c
Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 4955, and 4958bullet  
d
Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Enter amount of tax on line 40c reimbursed by the organization...........bullet  
e
All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter transaction? If "Yes," complete Form 8886-T ......................
40e
 
No
41List the states with which a copy of this return is filed. bullet
42aThe organization's books are in care of bulletBoard of Trustees Telephone no. bullet (337) 474-2298
Located at bullet2126 Oak Park BlvdLake Charles,LA ZIP + 4bullet70601
b
At any time during the calendar year, did the organization have an interest in or a signature or other authority over a financial account in a foreign country (such as a bank account, securities account, or other financial account)?
Yes
No
42b
 
No
If “Yes," enter the name of the foreign country: bullet
See the instructions for exceptions and filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR)
c
At any time during the calendar year, did the organization maintain an office outside the U.S.? . . .
42c
 
No
If “Yes," enter the name of the foreign country: bullet
43......bullet
and enter the amount of tax-exempt interest received or accrued during the tax year....bullet43
 
Yes
No
44a
Did the organization maintain any donor advised funds during the year? If "Yes," Form 990 must be completed instead of
Form 990-EZ................................
44a
 
No
b
Did the organization operate one or more hospital facilities during the year? If "Yes," Form 990 must be completedinstead of Form 990-EZ.............................
44b
 
No
c
Did the organization receive any payments for indoor tanning services during the year?.........
44c
 
No
d
If "Yes," to line 44c, has the organization filed a Form 720 to report these payments? If "No," provide an
explanation in Schedule O ............................
44d
 
 
45a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?.........
45a
 
No
45b
Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," Form 990 and Schedule R may need to be completed instead of Form 990-EZ (see instructions)......................
45b
 
 
Form 990-EZ (2014)
Form 990-EZ (2014)
Page 4
Yes
No
46
Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition tocandidates for public office? If “Yes," complete Schedule C, Part I. ..............
46
 
No
Part VI
Section 501(c)(3) organizations only All section 501(c)(3) organizations must answer questions 47-49b and 52, and complete the tables for lines 50 and 51 Check if the organization used Schedule O to respond to any question in this Part VI ................
Yes
No
47
Did the organization engage in lobbying activities or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II .......................
47
 
 
48
Is the organization a school as described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E ..
48
 
 
49a
Did the organization make any transfers to an exempt non-charitable related organization?......
49a
 
 
b
If "Yes," was the related organization a section 527 organization?................
49b
 
 
50
Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key employees) who each received more than $100,000 of compensation from the organization. If there is none, enter "None."
(a) Name and title of each employee (b) Average
hours per week
devoted to position		 (c) Reportable compensation
(Forms W-2/1099-MISC) 		(d) Health benefits, contributions to employee benefit plans, and deferred compensation (e) Estimated amount of other compensation
 
f
Total number of other employees paid over $100,000 .................bullet  

51
Complete this table for the organization's five highest compensated independent contractors who each received more than $100,000 of compensation from the organization. If there is none, enter "None."
(a) Name and business address of each independent contractor (b) Type of service (c) Compensation
 
d
Total number of other independent contractors each receiving over $100,000..........bullet  
52
Did the organization complete Schedule A? NOTE. All Section 501(c)(3) organizations must attach a completed Schedule A ...............bullet
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
Preparer's signature
Date
PTIN
Firm's name bullet

Firm's EIN bullet
Firm's address bullet



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
Form 990-EZ (2014)


Form 990-EZ, Special Condition Description:
Special Condition Description

Additional Data


Software ID:  
Software Version:  
SCHEDULE N
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Liquidation, Termination, Dissolution, or Significant Disposition of Assets
bullet Complete if the organization answered "Yes" to Form 990, Part IV, lines 31 or 32; or Form 990-EZ, line 36.
bullet Attach certified copies of any articles of dissolution, resolutions, or plans.
bullet Attach to Form 990 or 990-EZ.
bulletInformation about Schedule N (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2014
Open to Public
Inspection
Name of the organization
Insulators Local 112 Health and Welfare Fund
 
Employer identification number
72-6035885
Part I
Liquidation, Termination, or Dissolution. Complete this part if the organization answered "Yes" to Form 990, Part IV, line 31, or Form 990-EZ, line 36.
Part I can be duplicated if additional space is needed.
1(a)Description of asset(s)
distributed or transaction
expenses paid		 (b)Date of
distribution		 (c)Fair market value of
asset(s) distributed or
amount of transaction
expenses		 (d)Method of
determining FMV for
asset(s) distributed or
transaction expenses		 (e)EIN of recipient (f)Name and address of recipient (g)IRC section
of recipient(s) (if
tax-exempt) or type
of entity
Cash and investments transferred to the Southwest Health Benefit Fund. 09-01-2014 601,792 Cash stated at fair value, which equates with cost. Market value of investments provided by SEI Private Trust Company. 75-6012126 Southwest Health Benefit Fund
 
8841 Gulf Freeway STE 304
Houston,TX77017 		501(c)9




















Yes
No
2
Did or will any officer, director, trustee, or key employee of the organization:
a
Become a director or trustee of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . . .
2a
Yes
 
b
Become an employee of, or independent contractor for, a successor or transferee organization? . . . . . . . . . . . . . . . .
2b
 
No
c
Become a direct or indirect owner of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . .
2c
 
No
d
Receive, or become entitled to, compensation or other similar payments as a result of the organization's liquidation, termination, or dissolution? . . . . .
2d
 
No
e
If the organization answered "Yes" to any of the questions on lines 2a through 2d, provide the name of the person involved and explain in Part III. bullet
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or Form 990-EZ.
Cat. No. 50087Z
Schedule N (Form 990 or 990-EZ) (2014)

Schedule N (Form 990 or 990-EZ) (2014)
Page 2
Part I
Liquidation, Termination, or Dissolution (continued)
Note. If the organization distributed all of its assets during the tax year, then Form 990, Part X, column (B), line 16 (Total assets), and line 26 (Total liabilities), should equal -0-.
Yes
No
3
Did the organization distribute its assets in accordance with its governing instrument(s)? If "No," describe in Part III . . . . . . . . . . .
3
Yes
 
4a
Is the organization required to notify the attorney general or other appropriate state official of its intent to dissolve, liquidate, or terminate? . . . . . .
4a
 
No
b
If "Yes," did the organization provide such notice? . . . . . . . . . . . . . . . . . . . . . . . . . .
4b
 
No
5
Did the organization discharge or pay all of its liabilities in accordance with state laws? . . . . . . . . . . . . . . . . .
5
Yes
 
6a
Did the organization have any tax-exempt bonds outstanding during the year? . . . . . . . . . . . . . . . . . . . .
6a
 
No
b
If "Yes" to line 6a, did the organization discharge or defease all of its tax-exempt bond liabilities during the tax year in accordance with the Internal Revenue Code and state laws?
6b
 
 
c
If "Yes" to line 6b, describe in Part III how the organization defeased or otherwise settled these liabilities. If "No" to line 6b, explain in Part III.

Part II
Sale, Exchange, Disposition, or Other Transfer of More Than 25% of the Organization's Assets. Complete this part if the organization answered "Yes" to Form 990, Part IV, line 32, or Form 990-EZ, line 36. Part II can be duplicated if additional space is needed.
1(a) Description of asset(s)
distributed or transaction
expenses paid		 (b) Date of
distribution		 (c) Fair market value of
asset(s) distributed or
amount of transaction
expenses		 (d) Method of
determining FMV for
asset(s) distributed or
transaction expenses		 (e) EIN of recipient (f) Name and address of recipient (g) IRC section
of recipient(s) (if
tax-exempt) or type
of entity
















Yes
No
2
Did or will any officer, director, trustee, or key employee of the organization:
a
Become a director or trustee of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . . .
2a
Yes
 
b
Become an employee of, or independent contractor for, a successor or transferee organization? . . . . . . . . . . . . . . . .
2b
 
No
c
Become a direct or indirect owner of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . . .
2c
 
No
d
Receive, or become entitled to, compensation or other similar payments as a result of the organization’s significant disposition of assets? . . . . . . .
2d
 
No
e
If the organization answered "Yes" to any of the questions on lines 2a through 2d, provide the name of the person involved and explain in Part III. bullet
Schedule N(Form 990 or 990-EZ) (2014)

Schedule N (Form 990 or 990-EZ) (2014)
Page 3
Part III
Supplemental Information. Provide the information required by Part I, lines 2e and 6c, and Part II, line 2e. Also complete this part to provide any additional information.
Return Reference Explanation
Part I, Line 2e: Person(s) Involved: Kevin Smith
Part I, Line 2e: Explanation of Involvement: Kevin Smith is a trustee of the Southwest Health Benefit Fund.
Schedule N (Form 990 or 990-EZ) (2014)


Additional Data


Software ID:  
Software Version:  


SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or 990-EZ or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
MediumBullet Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2014
Open to Public
Inspection
Name of the organization
Insulators Local 112 Health and Welfare Fund
 
Employer identification number

72-6035885
Return Reference Explanation
Form 990-EZ, Part I, Line 4 - Other Investment Income Description: Mutual Fund Earnings. Amount: 6,328.
Form 990-EZ, Part I, Line 8 - Other Revenue Description: Misc.. Amount: 904. Description: Change in Hour Bank and IBNR. Amount: 64,728. Total to Form 990-EZ, line 8: 65,632.
Form 990-EZ, Part I, Line 16 - Other Expenses Description: Misc.. Amount: 665. Description: Wage and Fringe Reimbursement. Amount: 199. Description: Depreciation. Amount: 45. Description: Transfer of assets to the Southwest Health Benefit Fund (EIN: 75-6012126). Amount: 601,792. Total to Form 990-EZ, line 16: 602,701.
Form 990-EZ, Part II, Line 24 - Other Assets Description: Accounts Receivable. Beg. of Year Amount: 9,048. End of Year Amount: 0. Description: Prepaid Insurance. Beg. of Year Amount: 6,257. End of Year Amount: 0. Description: Other Depreciable Assets. Beg. of Year Amount: 674. End of Year Amount: 0.
Form 990-EZ, Part II, Line 26 - Other Liabilities Description: Accounts Payable. Beg. of Year Amount: 9,110. End of Year Amount: 0. Description: Claims Incurred but Not Reported. Beg. of Year Amount: 13,000. End of Year Amount: 0. Description: Hour Bank. Beg. of Year Amount: 51,728. End of Year Amount: 0.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2014

Additional Data


Software ID:  
Software Version:  

TY 2014 TransferPrsnlBnftContractsDecl
Name:
Insulators Local 112 Health and Welfare Fund
EIN: 72-6035885
Declaration:
The organization did not, during the year, receive any funds, directly,or indirectly, to pay premiums on a personal benefit contract.The organization, did not, during the year, pay any premiums, directly,or indirectly, on a personal benefit contract.