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 Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2017
Open to Public
Inspection
Name of the organization
PAVERS & ROAD BUILDERS DC
WELFARE FUND
Employer identification number

13-5562753
Return Reference Explanation
FORM 990, PAGE 2, PART III, LINE 4D TO PROVIDE HEALTH & WELFARE BENEFITS TO PARTICIPANTS & THEIR DEPENDENTS
FORM 990, PAGE 6, PART VI, LINE 11B NO REVIEW WAS OR WILL BE CONDUCTED.
FORM 990, PAGE 6, PART VI, LINE 15A APPROVED BY BOARD OF TRUSTEES
FORM 990, PAGE 6, PART VI, LINE 15B APPROVED BY BOARD OF TRUSTEES
FORM 990, PAGE 6, PART VI, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS & FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST
FORM 990, PART XI, LINE 9 MEDICARE PART D REIMBURSE -191,671 MEDICARE PART D REFUND 191,671
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2017


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