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
CITY OF SOUTH SAN FRANCISCO
VEBA HEALTH SAVINGS TRUST
Employer identification number

46-5297770
Return Reference Explanation
FORM 990, PART VI, SECTION A, LINE 7B THE TRUSTEE, WHICH IS THE GOVERNING BODY OF THE TRUST, IS A DIRECTED TRUSTEE WHO TAKES CERTAIN DIRECTION REGARDING THE TRUST FROM THE PLAN ADMINISTRATOR (OR ITS DESIGNEE) AND THE MEMBERS.
FORM 990, PART VI, SECTION A, LINE 8A THERE WERE NO MEETINGS.
FORM 990, PART VI, SECTION A, LINE 8B THERE ARE NO COMMITTEES.
FORM 990, PART VI, SECTION B, LINE 11B THE TRUSTEE REVIEWS THE FORM 990 BASED UPON THE FINANCIAL RECORDS FOR THE ORGANIZATION AND EXECUTES IT.
FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON WRITTEN REQUEST TO THE ORGANIZATION. THE INFORMATION IS THEN MAILED TO THE REQUESTING PARTY.
FORM 990, PART VII CONTACT ADDRESSES FOR OFFICERS, DIRECTORS, ETC MATRIX TRUST COMPANY - 717 17TH STREET, SUITE 1300, DENVER, CO 80202.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990) 2021


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