TY 2022 Form 990

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," on Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
SchDMd Bullet

Attach to Form 990.
SchDMd Bullet

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

OMB No. 1545-0047

2021

Open to Public Inspection

Name of the organization

CONSTRUCTION WORKERS OF LAKE COUNTY -
HRA TRUST FUND

Employer identification number

47-4459297

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate value of contributions to (during year)
3	Aggregate value of grants from (during year)
4	Aggregate value at end of year ........

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization’s property, subject to the organization’s exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements.
Complete if the organization answered "Yes" on Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements ......................	2a
b	Total acreage restricted by conservation easements ....................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 7/25/06, and not on a historic structure listed in the National Register ...	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .............................

Yes No

In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" on Form 990, Part IV, line 8.

If the organization elected, as permitted under FASB ASC 958, not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under FASB ASC 958, to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenue included on Form 990, Part VIII, line 1 ......................... SchDMd Bullet

(ii)

Assets included in Form 990, Part X ............................... SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under FASB ASC 958 relating to these items:

Revenue included on Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

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

Cat. No. 52283D

Schedule D (Form 990) 2021

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?...

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No


b	If "Yes," explain the arrangement in Part XIII and complete the following table:		Amount
c	Beginning balance .............................	1c
d	Additions during the year ............................	1d
e	Distributions during the year ..........................	1e
f	Ending balance ................................	1f

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ...

Yes No

If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ....

Part V

Endowment Funds.
Complete if the organization answered "Yes" on Form 990, Part IV, line 10.

		(a) Current year	(b) Prior year	(c) Two years back	(d) Three years back	(e) Four years back

1a	Beginning of year balance ....
b	Contributions ...
c	Net investment earnings, gains, and losses
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Term endowment SchDMd Bullet

The percentages on lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) Unrelated organizations .................

3a(i)

(ii) Related organizations .................

3a(ii)

If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(a) Cost or other basis (investment)	(b) Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value

1a	Land .....
b	Buildings ....
c	Leasehold improvements
d	Equipment ....
e	Other .....
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..		0

Schedule D (Form 990) 2021

Page 3

Part VII

Investments - Other Securities.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)	(b) Book value	(c) Method of valuation: Cost or end-of-year market value
(1) Financial derivatives.........
(2) Closely-held equity interests........
(3)Other
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

Investments - Program Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment	(b) Book value	(c) Method of valuation: Cost or end-of-year market value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	140,881
2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII

Schedule D (Form 990) 2021

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total revenue, gains, and other support per audited financial statements .......			1	1,310,447
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a	-156,322
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................			2e	-156,322
3	Subtract line 2e from line 1..................			3	1,466,769
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a	500
b	Other (Describe in Part XIII.) ...........	4b
c	Add lines 4a and 4b....................			4c	500
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	1,467,269

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........			1	223,751
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities .........	2a
b	Prior year adjustments ............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d....................			2e	0
3	Subtract line 2e from line 1...................			3	223,751
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a	500
b	Other (Describe in Part XIII.) ............	4b
c	Add lines 4a and 4b.....................			4c	500
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	224,251

Part XIII

Supplemental Information

Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b; Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Return Reference	Explanation
PART X, LINE 2:	ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE THE PLAN TO EVALUATE TAX POSITIONS TAKEN BY THE PLAN AND RECOGNIZE A TAX LIABILITY IF THE PLAN HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE TAX AUTHORITIES. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS.

Return Reference

Explanation

PART X, LINE 2:

ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE THE PLAN TO EVALUATE TAX POSITIONS TAKEN BY THE PLAN AND RECOGNIZE A TAX LIABILITY IF THE PLAN HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE TAX AUTHORITIES. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS.

Schedule D (Form 990) 2021

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

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

OMB No. 1545-0047

2022

Open to Public Inspection

Name of the organization

CONSTRUCTION WORKERS OF LAKE COUNTY -
HRA TRUST FUND

Employer identification number

47-4459297

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes on Line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain .....

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on Line 1a? ....

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? .............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Participate in, or receive payment from, an equity-based compensation arrangement? .........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ....................

Any related organization? .......................

If "Yes," on line 5a or 5b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ..................

Any related organization? ......................

If "Yes," on line 6a or 6b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III ..........................

If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

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

Cat. No. 50053T

Schedule J (Form 990) 2022

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2, 1099-MISC compensation, and/or 1099-NEC			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column (B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1MICHAEL CAMPBELL UNION TRUSTEE (SECRETARY)	(i) (ii)	0 ------------- 222,322	0 ------------- 0	0 ------------- 0	0 ------------- 113,064	0 ------------- 16,958	0 ------------- 352,344	0 ------------- 0
2WILLIAM K ROACH UNION TRUSTEE	(i) (ii)	0 ------------- 197,912	0 ------------- 0	0 ------------- 3,963	0 ------------- 97,547	0 ------------- 14,463	0 ------------- 313,885	0 ------------- 0
3RONALD DILLINGHAM UNION TRUSTEE	(i) (ii)	0 ------------- 186,600	0 ------------- 0	0 ------------- 0	0 ------------- 95,918	0 ------------- 16,914	0 ------------- 299,432	0 ------------- 0
4SCOTT SPARKS UNION TRUSTEE	(i) (ii)	0 ------------- 186,705	0 ------------- 0	0 ------------- 1,177	0 ------------- 93,512	0 ------------- 14,463	0 ------------- 295,857	0 ------------- 0

Schedule J (Form 990) 2022

Page 3

Part III

Supplemental Information

Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.

Return Reference	Explanation

Schedule J (Form 990) 2022

Additional Data

Software ID:
Software Version:

- 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

CONSTRUCTION WORKERS OF LAKE COUNTY -
HRA TRUST FUND

Employer identification number

47-4459297

Return Reference	Explanation
FORM 990, PART VI, SECTION A, LINE 8B	THE FUND DOES NOT HAVE ANY SEGREGATED COMMITTEES WHICH ACT ON BEHALF OF THE GOVERNING BODY.
FORM 990, PART VI, SECTION B, LINE 11B	THE FORM 990 IS PROVIDED TO THE ENTIRE BOARD OF TRUSTEES PRIOR TO FILING. THE TRUSTEES REVIEW THE FORM AND UPON FULLY UNDERSTANDING THE COMPLETED FORM 990, IT IS APPROVED, SIGNED AND SUBMITTED TO THE IRS.
FORM 990, PART VI, SECTION C, LINE 19	THE GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE FUND OFFICE.

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:
Software Version:

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SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990.
MediumBullet

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

OMB No. 1545-0047

2021

Open to Public Inspection

Name of the organization

CONSTRUCTION WORKERS OF LAKE COUNTY -
HRA TRUST FUND

Employer identification number

47-4459297

Part I

Identification of Disregarded Entities. Complete if the organization answered "Yes" on Form 990, Part IV, line 33.

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1)CONSTRUCTION WORKERS PENSION TRUST FUND - LAKE COUNTY AND VIC 200 W 84TH DRIVE MERRILLVILLE,IN46410 35-6030666	TO PROVIDE RETIREMENT BENEFITS FOR ELIGIBLE PARTICIPANTS	IN	401(A)	N/A	N/A		No
(2)LIUNA LOCAL UNION NO 81	CONTRIBUTING EMPLOYER						No
(3)LIUNA LOCAL UNION NO 41	CONTRIBUTING EMPLOYER						No

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

Cat. No. 50135Y

Schedule R (Form 990) 2021

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, because it had one or more related organizations treated as a partnership during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No	(k) Percentage ownership

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	Yes	No
(1) 3 D COMPANY INC	CONTRIBUTING EMPLOYER								No
(2) A C M S GROUP INC	CONTRIBUTING EMPLOYER								No
(3) ABLE MASONRY DEVELOP	CONTRIBUTING EMPLOYER								No
(4) ADAM VENTURES LLC DB	CONTRIBUTING EMPLOYER								No
(5) ADAMS MASONRY INC	CONTRIBUTING EMPLOYER								No
(6) ADVANCED CONCRETE SA	CONTRIBUTING EMPLOYER								No
(7) ADVANTAGE IND'L SYST	CONTRIBUTING EMPLOYER								No
(8) ADVANTAGE PAVING	CONTRIBUTING EMPLOYER								No
(9) AIRMARKING CO INC	CONTRIBUTING EMPLOYER								No
(10) ALL ACCESS LLC	CONTRIBUTING EMPLOYER								No
(11) ALLIANCE DEMOLITION	CONTRIBUTING EMPLOYER								No
(12) AMER DEMOLITION CORP	CONTRIBUTING EMPLOYER								No
(13) AMER MECH SVCS	CONTRIBUTING EMPLOYER								No
(14) AMEX NOOTER LLC	CONTRIBUTING EMPLOYER								No
(15) ARGO CONSTRUCTION LL	CONTRIBUTING EMPLOYER								No
(16) ASH MANAGEMENT SERVI	CONTRIBUTING EMPLOYER								No
(17) ATLANTIC LINING CO I	CONTRIBUTING EMPLOYER								No
(18) ATLAS EXCAVATING INC	CONTRIBUTING EMPLOYER								No
(19) AUSTGEN EQUIP INC	CONTRIBUTING EMPLOYER								No
(20) B & D SEWERBACKHOE	CONTRIBUTING EMPLOYER								No
(21) B M W C CONSTR INC	CONTRIBUTING EMPLOYER								No
(22) BEATY CONSTR	CONTRIBUTING EMPLOYER								No
(23) BERGLUND CONSTR CO	CONTRIBUTING EMPLOYER								No
(24) BERKEL & CO CONTR	CONTRIBUTING EMPLOYER								No
(25) BIESEN EXCAVATING IN	CONTRIBUTING EMPLOYER								No
(26) BLACK & VEATCH CONST	CONTRIBUTING EMPLOYER								No
(27) BLUE RIVER ENVIRO &	CONTRIBUTING EMPLOYER								No
(28) BLUFF CITY MATERIALS	CONTRIBUTING EMPLOYER								No
(29) BORE-IT CORP	CONTRIBUTING EMPLOYER								No
(30) BOWEN ENG CORP	CONTRIBUTING EMPLOYER								No
(31) BOYD ASPHALT INC	CONTRIBUTING EMPLOYER								No
(32) BRANDENBURG IND'L SV	CONTRIBUTING EMPLOYER								No
(33) BROCK INDUSTRIAL SER	CONTRIBUTING EMPLOYER								No
(34) BULL'S-EYE BORING IN	CONTRIBUTING EMPLOYER								No
(35) C & S CONCRETE CONST	CONTRIBUTING EMPLOYER								No
(36) C R I CONSTR SRVCS I	CONTRIBUTING EMPLOYER								No
(37) CALUMET CITY PLBG &	CONTRIBUTING EMPLOYER								No
(38) CASPER CONSTR INC	CONTRIBUTING EMPLOYER								No
(39) CE HUGHES MILLING IN	CONTRIBUTING EMPLOYER								No
(40) CHARPS WELDING & FAB	CONTRIBUTING EMPLOYER								No
(41) CHESAPEAKE CONTAINME	CONTRIBUTING EMPLOYER								No
(42) CLARK CONSTRUCTION	CONTRIBUTING EMPLOYER								No
(43) COBRA CONCRETE CUTTI	CONTRIBUTING EMPLOYER								No
(44) COLBY & CO INC	CONTRIBUTING EMPLOYER								No
(45) COLFAX CORP	CONTRIBUTING EMPLOYER								No
(46) COLVIN MASONRY INC	CONTRIBUTING EMPLOYER								No
(47) COMET CONTRACTING	CONTRIBUTING EMPLOYER								No
(48) COMPLETE PIPE LINING	CONTRIBUTING EMPLOYER								No
(49) CONCRETE BY WAGNER	CONTRIBUTING EMPLOYER								No
(50) CONCRETE CUTTING & B	CONTRIBUTING EMPLOYER								No
(51) CONSTRUCTION BY CAMC	CONTRIBUTING EMPLOYER								No
(52) CONTN'L PIPELINE SVC	CONTRIBUTING EMPLOYER								No
(53) CONTRACTORS RENTAL C	CONTRIBUTING EMPLOYER								No
(54) C-TECH CORP INC	CONTRIBUTING EMPLOYER								No
(55) D & M EXCAVATING INC	CONTRIBUTING EMPLOYER								No
(56) DE BOER EGOLF CORP	CONTRIBUTING EMPLOYER								No
(57) DELTA III INC	CONTRIBUTING EMPLOYER								No
(58) DIAMOND CORING CO IN	CONTRIBUTING EMPLOYER								No
(59) DOUG & STEVE CONSTR	CONTRIBUTING EMPLOYER								No
(60) DUNNET BAY CONSTR	CONTRIBUTING EMPLOYER								No
(61) DYER CONSTR CO INC	CONTRIBUTING EMPLOYER								No
(62) DYKSTRA CONCRETE CON	CONTRIBUTING EMPLOYER								No
(63) E & B PAVING INC	CONTRIBUTING EMPLOYER								No
(64) EINSPAHR INC	CONTRIBUTING EMPLOYER								No
(65) ELLAS CONSTR CO INC	CONTRIBUTING EMPLOYER								No
(66) ELLINGSON TRENCHLESS	CONTRIBUTING EMPLOYER								No
(67) ENVIRO CLEANSING COR	CONTRIBUTING EMPLOYER								No
(68) ERICKSON C J PLUMBIN	CONTRIBUTING EMPLOYER								No
(69) FABCON PRECAST LLC	CONTRIBUTING EMPLOYER								No
(70) FLUOR CONSTR INT'L I	CONTRIBUTING EMPLOYER								No
(71) FOX CONTR CORP	CONTRIBUTING EMPLOYER								No
(72) GALLAGHER ASPHALT	CONTRIBUTING EMPLOYER								No
(73) GARIUP CONSTR CO INC	CONTRIBUTING EMPLOYER								No
(74) GARY MATERIAL SUPPLY	CONTRIBUTING EMPLOYER								No
(75) GATLIN PLBG & HTG IN	CONTRIBUTING EMPLOYER								No
(76) GIBSON-LEWIS LLC	CONTRIBUTING EMPLOYER								No
(77) GLASROCK PRODUCTS IN	CONTRIBUTING EMPLOYER								No
(78) GOETTLE RICHARD INC	CONTRIBUTING EMPLOYER								No
(79) GOUGH INC	CONTRIBUTING EMPLOYER								No
(80) GRAYCOR COMPANIES	CONTRIBUTING EMPLOYER								No
(81) GRAYCOR IND'L CONSTR	CONTRIBUTING EMPLOYER								No
(82) GREAT LAKES TRACKWOR	CONTRIBUTING EMPLOYER								No
(83) GREEN DEMOLITION	CONTRIBUTING EMPLOYER								No
(84) GRIDLOCK TRAFFIC SYS	CONTRIBUTING EMPLOYER								No
(85) GRIFFIN CONTRACT DEW	CONTRIBUTING EMPLOYER								No
(86) GRIMMER CONSTR INC	CONTRIBUTING EMPLOYER								No
(87) GROUND CREW	CONTRIBUTING EMPLOYER								No
(88) H & G UNDERGROUND UT	CONTRIBUTING EMPLOYER								No
(89) H 3 CONCRETE INC	CONTRIBUTING EMPLOYER								No
(90) H R P CONSTRUCTION I	CONTRIBUTING EMPLOYER								No
(91) HALYARD CORPORATION	CONTRIBUTING EMPLOYER								No
(92) HARBISON WALKER INTE	CONTRIBUTING EMPLOYER								No
(93) HARD ROCK CONCRETE C	CONTRIBUTING EMPLOYER								No
(94) HASSE CONSTR CO INC	CONTRIBUTING EMPLOYER								No
(95) HAUTER BROTHERS INC	CONTRIBUTING EMPLOYER								No
(96) HAYES COMMERCIAL	CONTRIBUTING EMPLOYER								No
(97) HEELS AND HARDHATS C	CONTRIBUTING EMPLOYER								No
(98) HIGHWAY SAFETY SERVI	CONTRIBUTING EMPLOYER								No
(99) HOLLAND ASPHALT SRVC	CONTRIBUTING EMPLOYER								No
(100) HUMBER PAINTING	CONTRIBUTING EMPLOYER								No
(101) IL CONSTRUCTORS CORP	CONTRIBUTING EMPLOYER								No
(102) IN EARTH INC	CONTRIBUTING EMPLOYER								No
(103) INDIANA SIGN & BARRI	CONTRIBUTING EMPLOYER								No
(104) INFRASOURCE CONSTR L	CONTRIBUTING EMPLOYER								No
(105) INSITUFORM TECH USA	CONTRIBUTING EMPLOYER								No
(106) INTEGRATED DEMO SRVC	CONTRIBUTING EMPLOYER								No
(107) INTERSTATE IMPROVEME	CONTRIBUTING EMPLOYER								No
(108) IWANSKI MASONRY	CONTRIBUTING EMPLOYER								No
(109) J & E DUFF INC	CONTRIBUTING EMPLOYER								No
(110) J C DILLON INC	CONTRIBUTING EMPLOYER								No
(111) J C I BRIDGE GROUP	CONTRIBUTING EMPLOYER								No
(112) JAMES H DREW CORP	CONTRIBUTING EMPLOYER								No
(113) JEM CONCRETE DRILLS	CONTRIBUTING EMPLOYER								No
(114) JOE'S MASONRY	CONTRIBUTING EMPLOYER								No
(115) JOHNSON CREEK DEVELO	CONTRIBUTING EMPLOYER								No
(116) JOHNSTON W F CONSTR	CONTRIBUTING EMPLOYER								No
(117) KANTEX SUBSURFACE IN	CONTRIBUTING EMPLOYER								No
(118) KAPO CONSTRUCTION IN	CONTRIBUTING EMPLOYER								No
(119) KEVIN NUGENT CONSTR	CONTRIBUTING EMPLOYER								No
(120) KEY WEST METAL IND I	CONTRIBUTING EMPLOYER								No
(121) KNIOLA'S INDUSTRIAL	CONTRIBUTING EMPLOYER								No
(122) KOKOSING IND'L INC	CONTRIBUTING EMPLOYER								No
(123) KWIATKOWSKI MASONRY	CONTRIBUTING EMPLOYER								No
(124) L A SITES INC	CONTRIBUTING EMPLOYER								No
(125) L G S PLUMBING INC	CONTRIBUTING EMPLOYER								No
(126) L P S PAVEMENT CO	CONTRIBUTING EMPLOYER								No
(127) LA PORTE CONSTR CO I	CONTRIBUTING EMPLOYER								No
(128) LARSON-DANIELSON CON	CONTRIBUTING EMPLOYER								No
(129) LEE C CONSTR SVC INC	CONTRIBUTING EMPLOYER								No
(130) LEWIS CONSTR	CONTRIBUTING EMPLOYER								No
(131) M & J UNDERGROUND IN	CONTRIBUTING EMPLOYER								No
(132) M & O ENVIRONMENTAL	CONTRIBUTING EMPLOYER								No
(133) M G M EXCAVTING	CONTRIBUTING EMPLOYER								No
(134) MAC IND'L SRVCS INC	CONTRIBUTING EMPLOYER								No
(135) MALOW BARTON CO	CONTRIBUTING EMPLOYER								No
(136) MARSHALL G E INC	CONTRIBUTING EMPLOYER								No
(137) MARTELL ELECTRIC	CONTRIBUTING EMPLOYER								No
(138) MCALLISTER INC	CONTRIBUTING EMPLOYER								No
(139) METRO EXCAVATING COR	CONTRIBUTING EMPLOYER								No
(140) METZ ALEX SEWERS INC	CONTRIBUTING EMPLOYER								No
(141) MEYER C R AND SONS C	CONTRIBUTING EMPLOYER								No
(142) MICHELS PIPELINE INC	CONTRIBUTING EMPLOYER								No
(143) MICHELS TRENCHLESS I	CONTRIBUTING EMPLOYER								No
(144) MIDSTATES CONCRETE C	CONTRIBUTING EMPLOYER								No
(145) MIDWEST CONCRETE CUT	CONTRIBUTING EMPLOYER								No
(146) MIDWEST MOLE INC	CONTRIBUTING EMPLOYER								No
(147) MIDWEST REFRACTORY I	CONTRIBUTING EMPLOYER								No
(148) MIDWEST SERVICE GROU	CONTRIBUTING EMPLOYER								No
(149) MIDWESTERN CONTR INC	CONTRIBUTING EMPLOYER								No
(150) MIDWESTERN ELECTRIC	CONTRIBUTING EMPLOYER								No
(151) MILESTONE (FORMERLY	CONTRIBUTING EMPLOYER								No
(152) MILESTONE CONTRACTOR	CONTRIBUTING EMPLOYER								No
(153) MILESTONE FENCE LLC	CONTRIBUTING EMPLOYER								No
(154) MILLENIUM CONTRACTIN	CONTRIBUTING EMPLOYER								No
(155) MILLER PIPELINE CORP	CONTRIBUTING EMPLOYER								No
(156) MINNESOTA LIMITED IN	CONTRIBUTING EMPLOYER								No
(157) MODERN EDGE LLC	CONTRIBUTING EMPLOYER								No
(158) MORRISON CONSTR CO	CONTRIBUTING EMPLOYER								No
(159) N P L CONSTR CO	CONTRIBUTING EMPLOYER								No
(160) N P L GREAT LAKES LL	CONTRIBUTING EMPLOYER								No
(161) NW IN COMM FENCE CO	CONTRIBUTING EMPLOYER								No
(162) NAT'L WRECKING CO	CONTRIBUTING EMPLOYER								No
(163) NEWELL J & J	CONTRIBUTING EMPLOYER								No
(164) NICKELSON IND'L SERV	CONTRIBUTING EMPLOYER								No
(165) NORTHSTAR CONTRACTIN	CONTRIBUTING EMPLOYER								No
(166) O M I REFRACT (OAK M	CONTRIBUTING EMPLOYER								No
(167) OLSON CONSTR INC	CONTRIBUTING EMPLOYER								No
(168) OLTHOFF INC	CONTRIBUTING EMPLOYER								No
(169) ONEX CONSTR INC	CONTRIBUTING EMPLOYER								No
(170) OTIS MINNESOTA SERVI	CONTRIBUTING EMPLOYER								No
(171) PANGERE CORP	CONTRIBUTING EMPLOYER								No
(172) PASCHEN FH SN NIELS	CONTRIBUTING EMPLOYER								No
(173) PAUL'S CONSTR INC	CONTRIBUTING EMPLOYER								No
(174) PAVEY EXCAVATING CO	CONTRIBUTING EMPLOYER								No
(175) PIONEER ASSOCIATES I	CONTRIBUTING EMPLOYER								No
(176) PIRTANO CONSTR CO IN	CONTRIBUTING EMPLOYER								No
(177) POWERS & SONS CONSTR	CONTRIBUTING EMPLOYER								No
(178) PREMIUM CONCRETE SER	CONTRIBUTING EMPLOYER								No
(179) PROCISION BORING INC	CONTRIBUTING EMPLOYER								No
(180) PROFESSIONAL CONCRET	CONTRIBUTING EMPLOYER								No
(181) QUALITY SAW & SEAL I	CONTRIBUTING EMPLOYER								No
(182) R & C CONCRETE CONST	CONTRIBUTING EMPLOYER								No
(183) R & R SEWER-WATER &	CONTRIBUTING EMPLOYER								No
(184) R D MASONRY	CONTRIBUTING EMPLOYER								No
(185) R G CONSTRUCTION SRV	CONTRIBUTING EMPLOYER								No
(186) RACHEL CONTRACTING	CONTRIBUTING EMPLOYER								No
(187) RAILWORKS TRACK SVC	CONTRIBUTING EMPLOYER								No
(188) RAK IND'L SRVCS	CONTRIBUTING EMPLOYER								No
(189) RAM CONSTR SERVICES	CONTRIBUTING EMPLOYER								No
(190) RAMCORP INC	CONTRIBUTING EMPLOYER								No
(191) RC SMITH CONCRETE	CONTRIBUTING EMPLOYER								No
(192) RED ANT BORING	CONTRIBUTING EMPLOYER								No
(193) REFTECH INT'L	CONTRIBUTING EMPLOYER								No
(194) REICHELT PLUMBING IN	CONTRIBUTING EMPLOYER								No
(195) REX CONSTR CO INC	CONTRIBUTING EMPLOYER								No
(196) RIETH-RILEY CONSTR C	CONTRIBUTING EMPLOYER								No
(197) ROBERTS PIPELINE CON	CONTRIBUTING EMPLOYER								No
(198) ROCKY MOUNTAIN SPEC	CONTRIBUTING EMPLOYER								No
(199) ROGER & SONS CONSTR	CONTRIBUTING EMPLOYER								No
(200) ROY ZENERE TRUCKING	CONTRIBUTING EMPLOYER								No
(201) RYAN CONSTR INC	CONTRIBUTING EMPLOYER								No
(202) RYAN INC CENTRAL	CONTRIBUTING EMPLOYER								No
(203) S S S I INC	CONTRIBUTING EMPLOYER								No
(204) SAFE ENVIRO CORP	CONTRIBUTING EMPLOYER								No
(205) SCHOOL CITY OF HAMMO	CONTRIBUTING EMPLOYER								No
(206) SCURTO CEMENT CONSTR	CONTRIBUTING EMPLOYER								No
(207) SECURITY DOOR INC	CONTRIBUTING EMPLOYER								No
(208) SEGA AG CONTRACTORS	CONTRIBUTING EMPLOYER								No
(209) SHEET PILING SRVCS	CONTRIBUTING EMPLOYER								No
(210) SITE SERVICES INC	CONTRIBUTING EMPLOYER								No
(211) SLUSSERS GREEN THUMB	CONTRIBUTING EMPLOYER								No
(212) SOIL INSTALLERS DBA	CONTRIBUTING EMPLOYER								No
(213) SPECIALTIES COMPANY	CONTRIBUTING EMPLOYER								No
(214) SPIESS STEVE CONSTRU	CONTRIBUTING EMPLOYER								No
(215) SPRAY INSULATIONS	CONTRIBUTING EMPLOYER								No
(216) STATE BARRICADING	CONTRIBUTING EMPLOYER								No
(217) STEVENS ENG & CONSTR	CONTRIBUTING EMPLOYER								No
(218) STRESCORE INC	CONTRIBUTING EMPLOYER								No
(219) SUMMIT CIVIL SVCS LL	CONTRIBUTING EMPLOYER								No
(220) SUPERIOR CONSTR CO I	CONTRIBUTING EMPLOYER								No
(221) SUTTON ASPHALT LLC	CONTRIBUTING EMPLOYER								No
(222) SUTTON R V INC	CONTRIBUTING EMPLOYER								No
(223) T & K MASONRY INC	CONTRIBUTING EMPLOYER								No
(224) T L C PLUMBING INC	CONTRIBUTING EMPLOYER								No
(225) TAYLOR BROS CONSTR C	CONTRIBUTING EMPLOYER								No
(226) TENCO EXCAVATING INC	CONTRIBUTING EMPLOYER								No
(227) TETRA TECH	CONTRIBUTING EMPLOYER								No
(228) THE BLAKLEY CORP	CONTRIBUTING EMPLOYER								No
(229) THIENEMAN CONSTR INC	CONTRIBUTING EMPLOYER								No
(230) THORPE J T & SON INC	CONTRIBUTING EMPLOYER								No
(231) TODO EXCAVATING	CONTRIBUTING EMPLOYER								No
(232) TONN & BLANK CONSTR	CONTRIBUTING EMPLOYER								No
(233) TOTAL MILL SRVCS INC	CONTRIBUTING EMPLOYER								No
(234) TOWN & COUNTRY CONST	CONTRIBUTING EMPLOYER								No
(235) TRACK SERVICE INC	CONTRIBUTING EMPLOYER								No
(236) TRAFFIC CONTROL SPEC	CONTRIBUTING EMPLOYER								No
(237) TRAFFIC MANAGEMENT C	CONTRIBUTING EMPLOYER								No
(238) TRANCO IND'L SVCS IN	CONTRIBUTING EMPLOYER								No
(239) TRI-CREEK UNDERGROUN	CONTRIBUTING EMPLOYER								No
(240) UNITED CONSTR CO INC	CONTRIBUTING EMPLOYER								No
(241) UNITED PIPING INC	CONTRIBUTING EMPLOYER								No
(242) US HYDROVAC INC	CONTRIBUTING EMPLOYER								No
(243) V & H EXCAVATING CO	CONTRIBUTING EMPLOYER								No
(244) VISU-SEWER OF IL LL	CONTRIBUTING EMPLOYER								No
(245) WALKER G WM CONSTR C	CONTRIBUTING EMPLOYER								No
(246) WALSH CONSTR CO II L	CONTRIBUTING EMPLOYER								No
(247) WALSH CONSTR CO OF I	CONTRIBUTING EMPLOYER								No
(248) WARD ROBERT H & ASSO	CONTRIBUTING EMPLOYER								No
(249) WHITE CONSTRUCTION	CONTRIBUTING EMPLOYER								No
(250) WHITE J J INC	CONTRIBUTING EMPLOYER								No
(251) WHITEHEAD CONST INC	CONTRIBUTING EMPLOYER								No
(252) WILKIN INSULATION CO	CONTRIBUTING EMPLOYER								No
(253) WILLIAM CHARLES CONS	CONTRIBUTING EMPLOYER								No
(254) WILLIAMS REFRACTORY	CONTRIBUTING EMPLOYER								No
(255) WILSON EXCAVATING	CONTRIBUTING EMPLOYER								No
(256) WITECH CO INC	CONTRIBUTING EMPLOYER								No
(257) WOODRUFF & SONS INC	CONTRIBUTING EMPLOYER								No
(258) WRIGHT TRAFFIC CONTR	CONTRIBUTING EMPLOYER								No
(259) ZIESE & SONS EXCAVAT	CONTRIBUTING EMPLOYER								No
(260) ZIOLKOWSKI CONSTR IN	CONTRIBUTING EMPLOYER								No

Schedule R (Form 990) 2021

Page 3

Part V

Transactions With Related Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity .....................

b Gift, grant, or capital contribution to related organization(s) ............................

c Gift, grant, or capital contribution from related organization(s) ............................

d Loans or loan guarantees to or for related organization(s) ............................

e Loans or loan guarantees by related organization(s) ............................

f Dividends from related organization(s) ............................

g Sale of assets to related organization(s) ............................

h Purchase of assets from related organization(s) ............................

i Exchange of assets with related organization(s) ............................

j Lease of facilities, equipment, or other assets to related organization(s) .......................

k Lease of facilities, equipment, or other assets from related organization(s) ......................

l Performance of services or membership or fundraising solicitations for related organization(s) .....................

m Performance of services or membership or fundraising solicitations by related organization(s) .................

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................

Yes

o Sharing of paid employees with related organization(s) ............................

Yes

p Reimbursement paid to related organization(s) for expenses ............................

Yes

q Reimbursement paid by related organization(s) for expenses ............................

r Other transfer of cash or property to related organization(s) ............................

s Other transfer of cash or property from related organization(s) ............................

Yes

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved

Schedule R (Form 990) 2021

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 37.

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No	(k) Percentage ownership

Schedule R (Form 990) 2021

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R. See instructions.

Return Reference	Explanation

Schedule R (Form 990) 2021

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: HEALTH REIMBURSEMENT ACCOUNT PLAN
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	7
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	3
5	Total number of individuals employed in calendar year 2021 (Part V, line 2a) ......	5	0
6	Total number of volunteers (estimate if necessary) .............	6	0
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, Part I, line 11 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	0	0
9	Program service revenue (Part VIII, line 2g) .........	1,159,200	1,342,733
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	88,917	124,536
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	0	0
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	1,248,117	1,467,269
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4).....	114,408	115,909
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	0	0
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	94,816	108,342
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	209,224	224,251
19	Revenue less expenses. Subtract line 18 from line 12.......	1,038,893	1,243,018
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	4,636,572	5,836,160
21	Total liabilities (Part X, line 26).............	34,769	147,661
22	Net assets or fund balances. Subtract line 21 from line 20.....	4,601,803	5,688,499

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )
	THE PURPOSE OF THE PLAN IS TO MAKE PAYMENTS, ON BEHALF OF PARTICIPANTS AND DEPENDENTS, FOR THE PURPOSE OF CONTINUING OR ESTABLISHING ELIGIBILITY FOR A QUALIFIED HEALTH PLAN, IF SUCH PAYMENT IS A PAYMENT FOR QUALIFIED MEDICAL EXPENSES.

4b	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(D) Reportable compensation from the organization (W-2/1099-MISC/1099-NEC)	(E) Reportable compensation from related organizations (W-2/1099-MISC/1099-NEC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and title
(1) DAVID DEPRIZIO...................................................................... MANAGEMENT TRUSTEE (CHAIRM	1.00 .................	X	0	0	0
(2) ALEX GARIUP...................................................................... MANAGEMENT TRUSTEE	1.00 .................	X	0	0	0
(3) WILLIAM K ROACH...................................................................... UNION TRUSTEE	1.00 ................. 40.00	X	0	201,875	112,010
(4) MICHAEL CAMPBELL...................................................................... UNION TRUSTEE (SECRETARY)	1.00 ................. 40.00	X	0	222,322	130,022
(5) SCOTT SPARKS...................................................................... UNION TRUSTEE	1.00 ................. 40.00	X	0	187,882	107,975
(6) RONALD DILLINGHAM...................................................................... UNION TRUSTEE	1.00 ................. 40.00	X	0	186,600	112,832
(7) MARK GRIMMER...................................................................... MANAGEMENT TRUSTEE	1.00 .................	X	0	0	0

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	0	798,679	462,839

(A) Name and business address	(B) Description of services	(C) Compensation





2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 0

1a	Federated campaigns..	1a
b	Membership dues..	1b
c	Fundraising events..	1c
d	Related organizations	1d
e	Government grants (contributions)	1e

f	All other contributions, gifts, grants, and similar amounts not included above	1f

g	Noncash contributions included in lines 1a - 1f:$	1g

h Total. Add lines 1a-1f.......

		Business Code
2a	EMPLOYER CONTRIBUTIONS	900099	1,342,733	1,342,733
b
c
d
e
f	All other program service revenue.
g	Total. Add lines 2a–2f .....		1,342,733

3 Investment income (including dividends, interest, and othersimilar amounts) ......			124,536			124,536
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents			6a
b	Less: rental expenses			6b
c	Rental income or (loss)			6c
d	Net rental income or (loss).......
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory			7a
b	Less: cost or other basis and sales expenses			7b
c	Gain or (loss)			7c
d	Net gain or (loss).........
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
			8a
b	Less: direct expenses ...		8b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
			9a
b	Less: direct expenses ...		9b
c	Net income or (loss) from gaming activities..
10a	Gross sales of inventory, less returns and allowances ..
			10a
b	Less: cost of goods sold ..		10b
c	Net income or (loss) from sales of inventory..
Business Code			Miscellaneous Revenue
11a
b
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......
12	Total revenue. See instructions.....			1,467,269	1,342,733	0	124,536

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ...........
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............
4	Benefits paid to or for members .......	115,909
5	Compensation of current officers, directors, trustees, and key employees ...........
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........
7	Other salaries and wages........
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....
9	Other employee benefits .......
10	Payroll taxes ...........
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	3,212
c	Accounting ...........	14,818
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......	500
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	1,228
12	Advertising and promotion ....
13	Office expenses .......	3,319
14	Information technology ......
15	Royalties ..
16	Occupancy ...........
17	Travel ............
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....
20	Interest ...........
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..
23	Insurance ...	11,500
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	SHARED ADMINISTRATIVE E	73,490
b	BANK FEES	275
c
d
e	All other expenses
25	Total functional expenses. Add lines 1 through 24e	224,251
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

1	Cash–non-interest-bearing ........		108,131	1	74,039
2	Savings and temporary cash investments .........		28,529	2	156,695
3	Pledges and grants receivable, net ......			3
4	Accounts receivable, net .............		131,523	4	151,324
5	Loans and other receivables from any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
				5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
				6
7	Notes and loans receivable, net ...........			7
8	Inventories for sale or use ............			8
9	Prepaid expenses and deferred charges ......		9,534	9	9,429
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a
b	Less: accumulated depreciation	10b		10c
11	Investments—publicly traded securities .		4,358,855	11	5,444,673
12	Investments—other securities. See Part IV, line 11 .....			12
13	Investments—program-related. See Part IV, line 11 ..			13
14	Intangible assets ...............			14
15	Other assets. See Part IV, line 11 ...........			15
16	Total assets. Add lines 1 through 15 (must equal line 33)...		4,636,572	16	5,836,160

17	Accounts payable and accrued expenses .....	5,405	17	6,780
18	Grants payable ...		18
19	Deferred revenue .........		19
20	Tax-exempt bond liabilities .........		20
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
22	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
			22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ..		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17 - 24). Complete Part X of Schedule D	29,364	25	140,881
26	Total liabilities. Add lines 17 through 25..	34,769	26	147,661

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........		27
28	Net assets with donor restrictions ...........		28
	Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33.
29	Capital stock or trust principal, or current funds .....	0	29	0
30	Paid-in or capital surplus, or land, building or equipment fund ...	0	30	0
31	Retained earnings, endowment, accumulated income, or other funds	4,601,803	31	5,688,499
32	Total net assets or fund balances ...........	4,601,803	32	5,688,499
33	Total liabilities and net assets/fund balances ........	4,636,572	33	5,836,160