Short Form OMB No 1545-11 150

Form 980-EZ Return of Organization Exempt From Income Tax

section 501(c), 527, or 4947(a)(1) of the Internal Revenue code (except private foundations)
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^ Do not enter Social Security numbers on this form as it may be made public. 0 • • •
Department of the Treasury • •
Internal Revenue Seance ^ Information about Form 990-EZ and its instructions is at www. irs.gov/form990.
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A For the 2013 calendar year , or tax year beginning 7/1 , 2013, and ending 6/30 , 20 14
B Check it applicable C Name of organization D Employer identification number
G^ ❑ Address change Thurston County VEBA Health Savin g s Trust 45-5117067
❑ Name change Number and street (or P 0 box, if mail is not delivered to street address) Room/suite E Telephone number
Z ❑ Inmal return
106 South 5th Street 402-385-2343
!'^ ❑ Terminated
City or town, state or province, country, and ZIP or foreign postal code F Group Exemption
❑ Amended return
_ ❑ Application pending Pender NE 68355 Number ^

G Accounting Method 0 Cash ❑ Accrual Other (specify) ^ H Check ^ ❑ if the organization is not
o -
w M I Website : ^ required to attach Schedule B
J Tax-exempt status (check only one) - ❑ 501 (c)(3) ❑ 501 c 9 -4 (insert no) ❑ 4947 (a)( 1 ) or 0527 (Form 990, 990-EZ, or 990-PF).
K Form of organization ❑ Corporation ❑ Trust ❑ Association ❑ Other
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
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(Part II, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ . ^ $ 67587
Revenue , Expenses , and Changes in Net Assets or Fund Balances (see the instructions for Part I)
Check if the org anization used Schedule 0 to respond to any q uestion in this Part I .
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1 Contributions, gifts, grants, and similar amounts received . . . . . . . . . . 1 0
2 Program service revenue including government fees and contracts . . . . . . . 2 67550
rl^ 3 Membership dues and assessments . . . . . . . . . . . . . . . . 3 0
4 Investment income . . . . . . . . . . . . . 4 37
5a Gross amount from sale of assets other than inventory . . . . 5a 0
b Less: cost or other basis and sales expenses . . . . 5b 0
v;*
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
4) b Gross income from fundraising events (not including $ o of contributions
(7 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
b Less. cost of goods sold . . . . . . . . . 7b
c Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) . . . . . 7c 0
8 Other revenue (describe in Schedule 0) . . . . . . . . . . 8 0
9 Total revenue . Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 . . ^ 9 67587
10 Grants and similar amounts paid (list in Schedule 0) . . . cz, , ^^ , 0 0
11 Benefits paid to or for members ? /^, °'J 1 56490
12 Salaries, other compensation, and employee benefits . Cw^ rjj 12 0
2 13 Professional fees and other payments to independent contract rs . O . 13 0
zk
a 14 Occupancy, rent, utilities, and maintenance . . . . . ©^ . . . 14 0
W 15 Printing, publications, postage, and shipping . . . . . . . .^ pI/^ 15 0
16 Other expenses (describe in Schedule 0) . . . . . . . . . . . . vU . 16 1440
17 Total expenses . Add lines 10 through 16 17 57930
18 Excess or (deficit) for the year (Subtract line 17 from line 9) . . . 18 9657
y 19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with
end-of-year figure reported on pnor year's return ) . . . . . . . . . 19 62149
Z 20 Other changes in net assets or fund balances (explain in Schedule 0) . . . . . . . 20 0
21 Net assets or fund balances at end of year. Combine lines 18 throu g h 20 . ^ 21 71806
For Paperwork Reduction Act Notice , see the separate instructions . Cat No 106421 Form 99U-EL (2013)

?r f
Form 990-EZ (2013) Page 2
Balance Sheets (see the instructions for Part II)
Check if the organization used Schedule 0 to respond to any question in this Part II . ❑
(A) Beginning of year (B) End of year

22 Cash, savings, and investments . . . . . . . . 62149 22 71806

23 Land and buildings . . . . . . . . . . . . . . . . . 0 23 0
24 Other assets (describe in Schedule 0) . . . . . . . . . . . 0 24 0
25 Total assets . . . . . . . . . . . . . . . . . . 62149 25 71806
26 Total liabilities (describe in Schedule 0) 0 26 0
27 Net assets or fund balances (line 27 of column (B) must ag ree with line 21 ) 62149 27 , 71806
LEM Statement of Program Service Accomplishments (see the instructions for Part III)
Expenses
Check if the organization used Schedule 0 to respond to any question in this Part III • (Required for section
What is the organization's primary exempt purpose? Fund health reimbursement arrangement benefits 501(c)(3) and 501(c)(4)
organizations and section
Describe the organization's program service accomplishments for each of its three largest program services , 4947(a)(1) trusts, optional
as measured by expenses In a clear and concise manner, describe the services provided, the number of for others.)
persons benefited, and other relevant information for each program title.
28 H ealth reimbursemen t arran gement funded by organization had approximately 39 participants- who received-----
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medical care reimbursement in the amount of $56 , 490.27.
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(Grants $ ) If this amount includes forei g n g rants, check here ^ ❑ 28a 0
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(Grants $ ) If this amount includes forei g n grants, check here . ^ ❑ 29a 0
30
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(Grants $ ) If this amount includes foreign grants, check here ^ ❑ 30a 0
31 Other program services (describe in Schedule 0) . . . . . . . . . .
(Grants $ ) If this amount includes forei g n grants, check here . ^ ❑ 31a 0
32 Total program service expenses (add lines 28a through 31 a) . . . . . . ^ 32 0
List of Officers, Directors , Trustees , and Key Employees (list each one even if not compensated-see the instruct ions for Part IV)
Check if the organization used Schedule 0 to respond to any question in this Part IV . ❑
(c) Reportable (d) Health benefits,
(b) Average
compensation contributions to employee (e) Estimated amount of
(a) Name and title hours per week
(Forms W-2/1099-MISC) benefit plans, and other compensation
devoted to position
(rf not paid , enter -0-) deferred compensation

US-BANK,-NA-INST TRUST-& -CUSTODY-

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60 LIVINGSTON AVE., ST PAUL MN 55107 RUSTEE 1 HOUR 0 0 0

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Form 990-EZ (2013)

Form 990-EZ (201 ^) Page 3
Other Information (Note the Schedule A and personal benefit contract statement requirements in the
instructions for Part V) Check if the organization used Schedule 0 to respond to any question in this Part V [1
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 0 . . . . . . . . . . . . . . . 33 ✓
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
change on Schedule 0 (see instructions) . . . . . . . . . . . . . . . . . . . . . 34 ✓
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 ✓
b If "Yes," to line 35a, has the organization filed a Form 990-T for the year? If "No," provide an explanation in Schedule 0 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 ✓
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 . . . . . . . . . 36
37a Enter amount of political expenditures, direct or indirect, as described in the instructions ^ 137a
b Did the organization file Form 11 20-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 ✓
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 ^ ; section 4912 ^ ; section 4955 ^
b Section 501(c)(3) and 501(c)(4) 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) and 501(c)(4) organizations. Enter amount of tax imposed on
organization managers or disqualified persons during the year under sections 4912,
4955, and 4958 . . . . . . . . . . . . . . . ^
d Section 501(c)(3) and 501(c)(4) organizations Enter amount of tax on line 40c
reimbursed by the organization . . . . . . . ^
e All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter
transactions If "Yes," complete Form 8886-T . . . . . . . . . . . . . . . . . 40eI
41 List the states with which a copy of this return is filed ^ NOT APPLICABLE
42a The organization's books are in care of 110- US BANK NA INST . TRUST & CUSTODY Telephone no. ^ 651-495-4117
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Located at ^ 60 LIVINGSTON AVENUE, ST PAUL MN ZIP + 4 ^ 55107
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b At any time during the calendar year, did the organization have an interest in or a signature or other authority over Yes No
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: ^
See the instructions for exceptions and filing requirements for Form TD F 90-22.1, Report of Foreign Bank
and Financial Accounts.
c 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: ^
43 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041 -Check here
and enter the amount of tax-exempt interest received or accrued during the tax year . . ^ L 43 1
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 ✓
b Did the organization operate one or more hospital facilities during the year? If "Yes," Form 990 must be
completed instead of Form 990-EZ . . . . . . . . . . . . . . . . . . . . . 44b ✓
c Did the organization receive any payments for indoor tanning services during the year? . . . . . . . 44c ✓
d If "Yes" to line 44c, has the organization filed a Form 720 to report these payments ? If "No," provide an
explanation in Schedule 0 . . . . . . . . . . . . . . . . . . . 44d ✓
45a Did the organization have a controlled entity within the meaning of section 512 (b)(13)? . . . . . . .
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) . . . . . . . . . . . . . . . . . . 145bI I ✓
Form 990-EZ (2013)
Form 990-EZ (2013) Page 4
Yes No
46 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 . . . . . . . . . . . . qg I
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 0 to respond to any auestion 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)(ll)' 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 orqanization . If there is none , enter "None "
(d) Health benefits,
(b) Average (c) Reportable
contributions to employee (e) Estimated amount of
(a) Name and title of each employee hours per week compensation
benefit plans, and deferred other compensation
devoted to position (Forms W-2/1099-MISC)
compensation

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

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 I (b) Type of service I (c) Compensation

d Total number of other independent contractors each receivin

52 Did the organization complete Schedule A? Note . All section
nonexempt charitable trusts must attach a completed Sched

Under penalties of perjury, I declare that I have examined this return , including accomp^
true, correct , and complete Declaration of preparer (other than officer) is based on all it

Sign / Signatu re of officer

Here A,.I 4, g<--,4Vf us a,•k 61A acs d;
' Type or pnntnamed title

Pnnt/Type preparer's name Preparer's sigr

Paid
Preparer Jodie L. Rahi a
Firm's name ^ GENESIS EMPLOYEE BENS ITS II1
Use Only
Firm's address ^ 8000 W 78TH ST , SUITE 320 NE
May the IRS discuss this return with the preparer shown above
SCHEDULE 0 Supplemental Information to Form 990 or 990-EZ OMB No 1545-0047
(Form 990 or 990-EZ) Complete to provide information for responses to specific questions on O
Form 990 or 990-EZ or to provide any additional information.

Department of the Treasury ^ Attach to Form 990 or 990-EZ. • • • •

Internal Revenue Service ^ Information about Schedule 0 (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990. • -
Name of the organization Employer identification number
Thurston County Health Savinqs Trust 45-5117067

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PART I, -LINE- 16 - -ADMINISTRATIVE- FEE IN THE -AMOUNT- -OF $ 1, 439.90.

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For Paperwork Reduction Act Notice , see the Instructions for Form 990 or 990 -EZ. Cat No 51056K Schedule 0 (Form 990 or 990-EZ) (2013)