TY 2021 Form 990EZ

- TIN:

Form990EZ

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)

Do not enter social security numbers on this form as it may be made public.

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public
Inspection

For the 2021 calendar year, or tax year beginning 03-01-2021, and ending 02-28-2022

Check if applicable:

Address change

Name change

Initial return

Final return/terminated

Amended return

Application pending

C Name of organization
COUNTER DESIGN EMPLOYEE HEALTH TR

Number and street (or P. O. box, if mail is not delivered to street address)2381 Cullen Avenue
Room/suite

City or town, state or province, country, and ZIP or foreign postal code Evansville, IN47715

D Employer identification number

35-1975812

E Telephone number

(812) 477-1243

F Group Exemption
Number bullet

G Accounting Method: CashAccrualOther (specify) bullet

H Check bullet

required to attach Schedule B
(Form 990, 990-EZ, or 990-PF).I Website: bullet

J Tax-exempt status (check only one) - 501(c)(3) 501(c)( 9) bullet

(insert no.) 4947(a)(1) or 527

K Form of organization: CorporationTrustAssociationOther

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

$ 189,012

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.....................

1	Contributions, gifts, grants, and similar amounts received ....................	1	0
2	Program service revenue including government fees and contracts ................	2	0
3	Membership dues and assessments .............................	3	0
4	Investment income ....................................	4	0
5a	Gross amount from sale of assets other than inventory .......	5a	0
b	Less: cost or other basis and sales expenses ............	5b	0
c	Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) ......	5c	0
6	Gaming and fundraising events
a	Gross income from gaming (attach Schedule G if greater than $15,000)	6a	0
b	Gross income from fundraising events (not including $ 0 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	0
c	Less: direct expenses from gaming and fundraising events ...	6c	0
d	Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract line 6c)	6d	0
7a	Gross sales of inventory, less returns and allowances ......	7a	0
b	Less: cost of goods sold .............	7b	0
c	Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) .........	7c	0
8	Other revenue (describe in Schedule O) ....................	8	189,012
9	Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 ..............	9	189,012

10	Grants and similar amounts paid (list in Schedule O) ................	10	0
11	Benefits paid to or for members ......................	11	186,349
12	Salaries, other compensation, and employee benefits ................	12	0
13	Professional fees and other payments to independent contractors ............	13	0
14	Occupancy, rent, utilities, and maintenance ...................	14	0
15	Printing, publications, postage, and shipping ...................	15	0
16	Other expenses (describe in Schedule O) ...................	16	0
17	Total expenses. Add lines 10 through 16 .................	17	186,349

18	Excess or (deficit) for the year (Subtract line 17 from line 9) ............	18	2,663
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	66,589
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 ..........	21	69,252

For Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 10642I Form 990-EZ (2021)

Form 990-EZ (2021)

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................

66,589

69,252

23Land and buildings....................

24Other assets (describe in Schedule O) ..........

25Total assets......................

66,589

69,252

Total liabilities (describe in Schedule O) .............

27Net assets or fund balances (line 27 of column (B) must agree with line 21)

66,589

69,252

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? The purpose is for reimbursement of covered health care expenses incurred by members and their eligible 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 Payment for medical claims incurred by eligible members and dependents (Grants $ 0) If this amount includes foreign grants, check here ...			28a	156,831
29 Payment of prescription claims incurred by members & eligible dependents (Grants $ 0) If this amount includes foreign grants, check here ...			29a	29,518
30 (Grants $ ) If this amount includes foreign grants, check here ...			30a
31 Other program services (describe in Schedule O) ................ (Grants $ ) If this amount includes foreign grants, check here...	31a
32 Total program service expenses (add lines 28a through 31a)..........	32	186,349

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
Alvin C Tretter Trustee	1	0	0	0
Mary K Tretter Trustee	1	0	0	0

Form 990-EZ (2021)

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

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 ...................

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. ..........................

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

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

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

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 ................

37a

Enter amount of political expenditures, direct or indirect, as described in the instructions. bullet

37a

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

If “Yes," complete Schedule L, Part II and enter the total amount involved .

38b

Section 501(c)(7) organizations. Enter:

Initiation fees and capital contributions included on line 9.......

39a

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

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

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 4958 bullet

Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Enter amount of tax on line 40c reimbursed by the organization bullet

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

41List the states with which a copy of this return is filed. bullet

42a The organization's books are in care of bullet

Counter Design Co Inc
Telephone no. bullet

(812) 477-1243

Located at bullet

2381 Cullen AvenueEvansville, IN ZIP + 4 bullet

47715

Yes

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)? . .

42b

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).

At any time during the calendar year, did the organization maintain an office outside the U.S.? . . .

42c

If “Yes," enter the name of the foreign country: bullet

43 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041 - Check here ...... bullet

and enter the amount of tax-exempt interest received or accrued during the tax year .... bullet

Yes

44a

Did the organization maintain any donor advised funds during the year? If "Yes," Form 990 must be completed insteadof Form 990-EZ.............................

44a

Did the organization operate one or more hospital facilities during the year? If "Yes," Form 990 must be completedinstead of Form 990-EZ.............................

44b

Did the organization receive any payments for indoor tanning services during the year? .........

44c

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

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 (2021)

Page 4

Yes

Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition to candidates for public office? If “Yes," complete Schedule C, Part I. ...........

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

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 .......................

Is the organization a school as described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E ..

49a

Did the organization make any transfers to an exempt non-charitable related organization?......

49a

If "Yes," was the related organization a section 527 organization?................

49b

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

Total number of other employees paid over $100,000 ............. bullet

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

Total number of other independent contractors each receiving over $100,000.......... bullet

Did the organization complete Schedule A? NOTE. All section 501(c)(3) organizations must attach a
completed Schedule A ........................................ bullet

Yes No

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

	Signature of officer	Date

	Type or print name and title

Paid Preparer Use Only

Print/Type preparer's name

Preparer's signature

Date

Check if
self-employed

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

YesNo

Form 990-EZ (2021)

Additional Data

Software ID:	21013178
Software Version:	v1.00

Form 990-EZ, Special Condition Description:

Special Condition Description

- TIN:

SCHEDULE O
(Form 990)

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

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2021

Open to Public
Inspection

Name of the organization

COUNTER DESIGN EMPLOYEE HEALTH TR

Employer identification number

35-1975812

Return Reference	Explanation
Form 990-EZ, Part I, Line 8	Trust received contributions from Counter Design Co., Inc to fund health plan.
Form 990-EZ, Part IV	Duties related to trust include deposits into account and authorizing release of funds to fund health care expenses. Trustees are not paid any compensation for these duties.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990) 2021

Additional Data

Software ID:	21013178
Software Version:	v1.00

- TIN:

TY 2021 ReasonableCauseExplanation

Name:

COUNTER DESIGN EMPLOYEE HEALTH TR

EIN:

35-1975812

Software ID:

21013178

Software Version:

v1.00

Explanation:

Extension was filed electronically on June 29, 2022. Organization: COUNTER DESIGN EMPLOYEE HEALTH TR EIN: 35-1975812 Return Type: Form 8868 Return Year: 2021 Submission ID: 8600762022180c469984 Return Timestamp: 6/29/2022 7:30:11 AM Accepted Date: 6/29/2022 Thank you for using the 990 Online system for preparing and electronically filing your Form 8868 return. This email contains some important identifying information about the return we transmitted. You may want to keep this email in case you need to contact the IRS regarding your return. The return described above was transmitted to the IRS. The IRS has ACCEPTED the return. Congratulations.