Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| PART I, LINE 1: | THE ORGANIZATION'S MISSION IS 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 8B: | THE PLAN DOES NOT HAVE A COMMITTEE WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. |
| PART VI, LINE 11B: | FORM 990 WAS REVIEWED BY THE ADMINISTRATIVE OFFICE PRIOR TO BEING FILED. THE FORM 990 IS AVAILABLE TO THE TRUSTEES UPON REQUEST. |
| PART VI, LINE 12C: | TRUSTEES ARE REQUIRED TO NOTIFY THE PLAN OF ANY CHANGES IN 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: | THE BOARD OF TRUSTEES SERVES FOR NO COMPENSATION PAID FROM THE TRUST OR PAID BY THEIR EMPLOYERS FOR SERVICES TO THE TRUST. COMPENSATION PAID TO TRUSTEES BY THE TRUSTEES' EMPLOYERS IS REPORTED ON THE EMPLOYERS' ANNUAL PAYROLL TAX FILINGS AND IS NOT REPORTED OR KNOWN TO THE ADMINISTRATIVE OFFICE. |
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