401k Plan data: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN plan

ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 401k Plan overview

Plan Name	ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN
Plan identification number	001

ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

ST JOHNSVILLE A has sponsored the creation of one or more 401k plans.

Company Name: ST JOHNSVILLE A

Employer identification number (EIN): 201388111

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01
001 2021-01-01
001 2020-01-01
001 2019-01-01
001 2019-01-01
001 2018-01-01 CHRISTOPHER DURR 2019-06-17
001 2017-01-01 MICHELE DYGERT 2018-02-23
001 2016-01-01 MICHELE DYGERT 2017-09-22
001 2015-01-01 MICHELE DYGERT 2016-05-16
001 2014-01-01 MICHELE DYGERT MICHELE DYGERT 2015-07-30
001 2013-01-01 MICHELE DYGERT MICHELE DYGERT 2014-07-30
001 2012-01-01 MICHELE DYGERT MICHELE DYGERT 2013-10-11
001 2011-01-01 LISA M. VOLK LISA M. VOLK 2012-10-09
001 2010-01-01 LISA M. VOLK 2011-06-06

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2022-01-01
001	2021-01-01
001	2020-01-01
001	2019-01-01
001	2019-01-01
001	2018-01-01	CHRISTOPHER DURR	2019-06-17
001	2017-01-01	MICHELE DYGERT	2018-02-23
001	2016-01-01	MICHELE DYGERT	2017-09-22
001	2015-01-01	MICHELE DYGERT	2016-05-16
001	2014-01-01	MICHELE DYGERT		MICHELE DYGERT	2015-07-30
001	2013-01-01	MICHELE DYGERT		MICHELE DYGERT	2014-07-30
001	2012-01-01	MICHELE DYGERT		MICHELE DYGERT	2013-10-11
001	2011-01-01	LISA M. VOLK		LISA M. VOLK	2012-10-09
001	2010-01-01	LISA M. VOLK	2011-06-06

Plan Statistics for ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN

401k plan membership statisitcs for ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN

Measure Date Value
2022: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 183
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 104
Number of retired or separated participants receiving benefits 2022-01-01 1
Number of other retired or separated participants entitled to future benefits 2022-01-01 76
Total of all active and inactive participants 2022-01-01 181
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 181
Number of participants with account balances 2022-01-01 171
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 14
2021: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 179
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 107
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 61
Total of all active and inactive participants 2021-01-01 168
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 168
Number of participants with account balances 2021-01-01 150
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 13
2020: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 149
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 113
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 51
Total of all active and inactive participants 2020-01-01 164
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 164
Number of participants with account balances 2020-01-01 150
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 20
2019: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 124
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 5
Total of all active and inactive participants 2019-01-01 129
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 129
Number of participants with account balances 2019-01-01 28
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 0
2014: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 101
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 80
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 3
Total of all active and inactive participants 2014-01-01 83
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 83
Number of participants with account balances 2014-01-01 27
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 2
2013: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 120
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 90
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 7
Total of all active and inactive participants 2013-01-01 97
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 97
Number of participants with account balances 2013-01-01 37
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 132
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 113
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 7
Total of all active and inactive participants 2012-01-01 120
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 120
Number of participants with account balances 2012-01-01 41
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 1
2011: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 135
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 112
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 4
Total of all active and inactive participants 2011-01-01 116
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 116
Number of participants with account balances 2011-01-01 43
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 2

Measure	Date	Value
2022: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	183
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	104
Number of retired or separated participants receiving benefits	2022-01-01	1
Number of other retired or separated participants entitled to future benefits	2022-01-01	76
Total of all active and inactive participants	2022-01-01	181
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	181
Number of participants with account balances	2022-01-01	171
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	14
2021: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	179
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	107
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	61
Total of all active and inactive participants	2021-01-01	168
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	168
Number of participants with account balances	2021-01-01	150
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	13
2020: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	149
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	113
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	51
Total of all active and inactive participants	2020-01-01	164
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	164
Number of participants with account balances	2020-01-01	150
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	20
2019: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	124
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	5
Total of all active and inactive participants	2019-01-01	129
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	129
Number of participants with account balances	2019-01-01	28
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	0
2014: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	101
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	80
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	3
Total of all active and inactive participants	2014-01-01	83
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	83
Number of participants with account balances	2014-01-01	27
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	2
2013: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	120
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	90
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	7
Total of all active and inactive participants	2013-01-01	97
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	97
Number of participants with account balances	2013-01-01	37
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	132
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	113
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	7
Total of all active and inactive participants	2012-01-01	120
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	120
Number of participants with account balances	2012-01-01	41
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	1
2011: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	135
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	112
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	4
Total of all active and inactive participants	2011-01-01	116
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	116
Number of participants with account balances	2011-01-01	43
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	2

Financial Data on ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN

Measure	Date	Value
2022 : ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total income from all sources (including contributions)	2022-12-31	$-29,721
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$199,128
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$195,718
Expenses. Certain deemed distributions of participant loans	2022-12-31	$0
Value of total corrective distributions	2022-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$73,697
Value of total assets at end of year	2022-12-31	$521,524
Value of total assets at beginning of year	2022-12-31	$750,373
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$3,410
Total interest from all sources	2022-12-31	$1,226
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$10,011
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2022-12-31	$10,011
Assets. Real estate other than employer real property at beginning of year	2022-12-31	$0
Administrative expenses professional fees incurred	2022-12-31	$0
Assets. Corporate prefeered stocks other than exployer securities at beginning of year	2022-12-31	$0
Was this plan covered by a fidelity bond	2022-12-31	No
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$58,332
Participant contributions at end of year	2022-12-31	$33,444
Participant contributions at beginning of year	2022-12-31	$25,735
Participant contributions at end of year	2022-12-31	$1,120
Participant contributions at beginning of year	2022-12-31	$1,244
Assets. Other investments not covered elsewhere at end of year	2022-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2022-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2022-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2022-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2022-12-31	$0
Assets. Loans (other than to participants) at beginning of year	2022-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2022-12-31	$0
Administrative expenses (other) incurred	2022-12-31	$0
Liabilities. Value of operating payables at beginning of year	2022-12-31	$0
Total non interest bearing cash at beginning of year	2022-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-228,849
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$521,524
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$750,373
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Assets. partnership/joint venture interests at beginning of year	2022-12-31	$0
Investment advisory and management fees	2022-12-31	$334
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$471,335
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$710,402
Value of interest in pooled separate accounts at end of year	2022-12-31	$0
Value of interest in pooled separate accounts at beginning of year	2022-12-31	$0
Interest on participant loans	2022-12-31	$1,226
Value of interest in master investment trust accounts at end of year	2022-12-31	$0
Value of interest in master investment trust accounts at beginning of year	2022-12-31	$0
Value of interest in common/collective trusts at end of year	2022-12-31	$15,316
Value of interest in common/collective trusts at beginning of year	2022-12-31	$12,692
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2022-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2022-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2022-12-31	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2022-12-31	$0
Assets. Value of investments in 103.12 investment entities at end of year	2022-12-31	$0
Assets. Value of investments in 103.12 investment entities at beginning of year	2022-12-31	$0
Asset value of US Government securities at beginning of year	2022-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-114,655
Net investment gain/loss from pooled separate accounts	2022-12-31	$0
Net investment gain or loss from common/collective trusts	2022-12-31	$0
Net gain/loss from 103.12 investment entities	2022-12-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Assets. Invements in employer securities at beginning of year	2022-12-31	$0
Assets. Value of employer real property at beginning of year	2022-12-31	$0
Contributions received in cash from employer	2022-12-31	$15,365
Employer contributions (assets) at end of year	2022-12-31	$309
Employer contributions (assets) at beginning of year	2022-12-31	$300
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$195,718
Asset. Corporate debt instrument preferred debt at beginning of year	2022-12-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2022-12-31	$0
Contract administrator fees	2022-12-31	$3,076
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2022-12-31	No
Assets. Corporate common stocks other than exployer securities at beginning of year	2022-12-31	$0
Liabilities. Value of benefit claims payable at beginning of year	2022-12-31	$0
Assets. Value of buildings and other operty used in plan operation at beginning of year	2022-12-31	$0
Did the plan have assets held for investment	2022-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Liabilities. Value of acquisition indebtedness at beginning of year	2022-12-31	$0
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	BONADIO & CO LLP
Accountancy firm EIN	2022-12-31	161131146
2021 : ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$163,423
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$76,833
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$73,103
Expenses. Certain deemed distributions of participant loans	2021-12-31	$0
Value of total corrective distributions	2021-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$89,458
Value of total assets at end of year	2021-12-31	$750,373
Value of total assets at beginning of year	2021-12-31	$663,783
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$3,730
Total interest from all sources	2021-12-31	$411
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$14,244
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2021-12-31	$14,244
Was this plan covered by a fidelity bond	2021-12-31	No
If this is an individual account plan, was there a blackout period	2021-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$71,750
Participant contributions at end of year	2021-12-31	$25,735
Participant contributions at beginning of year	2021-12-31	$1,701
Participant contributions at end of year	2021-12-31	$1,244
Participant contributions at beginning of year	2021-12-31	$1,150
Assets. Other investments not covered elsewhere at end of year	2021-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2021-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2021-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2021-12-31	$0
Administrative expenses (other) incurred	2021-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$86,590
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$750,373
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$663,783
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Investment advisory and management fees	2021-12-31	$338
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$710,402
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$650,527
Value of interest in pooled separate accounts at end of year	2021-12-31	$0
Value of interest in pooled separate accounts at beginning of year	2021-12-31	$0
Interest on participant loans	2021-12-31	$411
Value of interest in master investment trust accounts at end of year	2021-12-31	$0
Value of interest in master investment trust accounts at beginning of year	2021-12-31	$0
Value of interest in common/collective trusts at end of year	2021-12-31	$12,692
Value of interest in common/collective trusts at beginning of year	2021-12-31	$10,075
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2021-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2021-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2021-12-31	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2021-12-31	$0
Assets. Value of investments in 103.12 investment entities at end of year	2021-12-31	$0
Assets. Value of investments in 103.12 investment entities at beginning of year	2021-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$59,310
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$17,708
Employer contributions (assets) at end of year	2021-12-31	$300
Employer contributions (assets) at beginning of year	2021-12-31	$330
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$73,103
Contract administrator fees	2021-12-31	$3,392
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2021-12-31	No
Did the plan have assets held for investment	2021-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	BONADIO & CO LLP
Accountancy firm EIN	2021-12-31	161131146
2020 : ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$163,335
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$6,586
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$0
Expenses. Certain deemed distributions of participant loans	2020-12-31	$0
Value of total corrective distributions	2020-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$71,092
Value of total assets at end of year	2020-12-31	$663,783
Value of total assets at beginning of year	2020-12-31	$507,034
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$6,586
Total interest from all sources	2020-12-31	$217
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$10,851
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2020-12-31	$10,851
Assets. Real estate other than employer real property at beginning of year	2020-12-31	$0
Assets. Corporate prefeered stocks other than exployer securities at beginning of year	2020-12-31	$0
Was this plan covered by a fidelity bond	2020-12-31	No
If this is an individual account plan, was there a blackout period	2020-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$55,000
Participant contributions at end of year	2020-12-31	$1,701
Participant contributions at beginning of year	2020-12-31	$6,304
Participant contributions at end of year	2020-12-31	$1,150
Participant contributions at beginning of year	2020-12-31	$1,541
Assets. Other investments not covered elsewhere at end of year	2020-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2020-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2020-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2020-12-31	$0
Assets. Loans (other than to participants) at beginning of year	2020-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2020-12-31	$0
Administrative expenses (other) incurred	2020-12-31	$0
Liabilities. Value of operating payables at beginning of year	2020-12-31	$0
Total non interest bearing cash at beginning of year	2020-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$156,749
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$663,783
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$507,034
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Assets. partnership/joint venture interests at beginning of year	2020-12-31	$0
Investment advisory and management fees	2020-12-31	$212
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-12-31	$650,527
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$497,706
Value of interest in pooled separate accounts at end of year	2020-12-31	$0
Value of interest in pooled separate accounts at beginning of year	2020-12-31	$0
Interest on participant loans	2020-12-31	$217
Value of interest in master investment trust accounts at end of year	2020-12-31	$0
Value of interest in master investment trust accounts at beginning of year	2020-12-31	$0
Value of interest in common/collective trusts at end of year	2020-12-31	$10,075
Value of interest in common/collective trusts at beginning of year	2020-12-31	$1,115
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2020-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2020-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2020-12-31	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2020-12-31	$0
Assets. Value of investments in 103.12 investment entities at end of year	2020-12-31	$0
Assets. Value of investments in 103.12 investment entities at beginning of year	2020-12-31	$0
Asset value of US Government securities at beginning of year	2020-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$81,175
Net investment gain/loss from pooled separate accounts	2020-12-31	$0
Net investment gain or loss from common/collective trusts	2020-12-31	$0
Net gain/loss from 103.12 investment entities	2020-12-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	No
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Assets. Invements in employer securities at beginning of year	2020-12-31	$0
Assets. Value of employer real property at beginning of year	2020-12-31	$0
Contributions received in cash from employer	2020-12-31	$16,092
Employer contributions (assets) at end of year	2020-12-31	$330
Employer contributions (assets) at beginning of year	2020-12-31	$368
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$0
Asset. Corporate debt instrument preferred debt at beginning of year	2020-12-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2020-12-31	$0
Contract administrator fees	2020-12-31	$6,374
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2020-12-31	No
Assets. Corporate common stocks other than exployer securities at beginning of year	2020-12-31	$0
Liabilities. Value of benefit claims payable at beginning of year	2020-12-31	$0
Assets. Value of buildings and other operty used in plan operation at beginning of year	2020-12-31	$0
Did the plan have assets held for investment	2020-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Liabilities. Value of acquisition indebtedness at beginning of year	2020-12-31	$0
Opinion of an independent qualified public accountant for this plan	2020-12-31	Disclaimer
Accountancy firm name	2020-12-31	BONADIO & CO., LLP
Accountancy firm EIN	2020-12-31	161131146
2019 : ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total income from all sources (including contributions)	2019-12-31	$216,075
Total income from all sources (including contributions)	2019-12-31	$216,075
Total loss/gain on sale of assets	2019-12-31	$0
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$47,377
Total of all expenses incurred	2019-12-31	$47,377
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$43,941
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$43,941
Expenses. Certain deemed distributions of participant loans	2019-12-31	$0
Expenses. Certain deemed distributions of participant loans	2019-12-31	$0
Value of total corrective distributions	2019-12-31	$0
Value of total corrective distributions	2019-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$147,810
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$147,810
Value of total assets at end of year	2019-12-31	$507,034
Value of total assets at end of year	2019-12-31	$507,034
Value of total assets at beginning of year	2019-12-31	$338,336
Value of total assets at beginning of year	2019-12-31	$338,336
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$3,436
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$3,436
Total interest from all sources	2019-12-31	$152
Total interest from all sources	2019-12-31	$152
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$12,087
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$12,087
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2019-12-31	$12,087
Total dividends received from registered investment company shares (eg mutual funds)	2019-12-31	$12,087
Assets. Real estate other than employer real property at beginning of year	2019-12-31	$0
Assets. Real estate other than employer real property at beginning of year	2019-12-31	$0
Assets. Corporate prefeered stocks other than exployer securities at beginning of year	2019-12-31	$0
Assets. Corporate prefeered stocks other than exployer securities at beginning of year	2019-12-31	$0
Was this plan covered by a fidelity bond	2019-12-31	No
Was this plan covered by a fidelity bond	2019-12-31	No
If this is an individual account plan, was there a blackout period	2019-12-31	Yes
If this is an individual account plan, was there a blackout period	2019-12-31	Yes
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Contributions received from participants	2019-12-31	$30,385
Contributions received from participants	2019-12-31	$30,385
Participant contributions at end of year	2019-12-31	$6,304
Participant contributions at end of year	2019-12-31	$6,304
Participant contributions at beginning of year	2019-12-31	$9,991
Participant contributions at beginning of year	2019-12-31	$9,991
Participant contributions at end of year	2019-12-31	$1,541
Participant contributions at end of year	2019-12-31	$1,541
Participant contributions at beginning of year	2019-12-31	$0
Participant contributions at beginning of year	2019-12-31	$0
Assets. Other investments not covered elsewhere at end of year	2019-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2019-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2019-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$109,691
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$109,691
Value of other receiveables (less allowance for doubtful accounts) at end of year	2019-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2019-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2019-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2019-12-31	$0
Assets. Loans (other than to participants) at beginning of year	2019-12-31	$0
Assets. Loans (other than to participants) at beginning of year	2019-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2019-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2019-12-31	$0
Administrative expenses (other) incurred	2019-12-31	$0
Administrative expenses (other) incurred	2019-12-31	$0
Liabilities. Value of operating payables at beginning of year	2019-12-31	$0
Liabilities. Value of operating payables at beginning of year	2019-12-31	$0
Total non interest bearing cash at beginning of year	2019-12-31	$0
Total non interest bearing cash at beginning of year	2019-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Value of net income/loss	2019-12-31	$168,698
Value of net income/loss	2019-12-31	$168,698
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$507,034
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$338,336
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$338,336
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Assets. partnership/joint venture interests at beginning of year	2019-12-31	$0
Assets. partnership/joint venture interests at beginning of year	2019-12-31	$0
Investment advisory and management fees	2019-12-31	$64
Investment advisory and management fees	2019-12-31	$64
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$497,706
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$497,706
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$328,345
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$328,345
Value of interest in pooled separate accounts at end of year	2019-12-31	$0
Value of interest in pooled separate accounts at end of year	2019-12-31	$0
Value of interest in pooled separate accounts at beginning of year	2019-12-31	$0
Value of interest in pooled separate accounts at beginning of year	2019-12-31	$0
Interest on participant loans	2019-12-31	$152
Interest on participant loans	2019-12-31	$152
Value of interest in master investment trust accounts at end of year	2019-12-31	$0
Value of interest in master investment trust accounts at end of year	2019-12-31	$0
Value of interest in master investment trust accounts at beginning of year	2019-12-31	$0
Value of interest in master investment trust accounts at beginning of year	2019-12-31	$0
Value of interest in common/collective trusts at end of year	2019-12-31	$1,115
Value of interest in common/collective trusts at end of year	2019-12-31	$1,115
Value of interest in common/collective trusts at beginning of year	2019-12-31	$0
Value of interest in common/collective trusts at beginning of year	2019-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2019-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2019-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2019-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2019-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2019-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2019-12-31	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2019-12-31	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2019-12-31	$0
Assets. Value of investments in 103.12 investment entities at end of year	2019-12-31	$0
Assets. Value of investments in 103.12 investment entities at end of year	2019-12-31	$0
Assets. Value of investments in 103.12 investment entities at beginning of year	2019-12-31	$0
Assets. Value of investments in 103.12 investment entities at beginning of year	2019-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-12-31	$7,851
Asset value of US Government securities at beginning of year	2019-12-31	$0
Asset value of US Government securities at beginning of year	2019-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$56,026
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$56,026
Net investment gain/loss from pooled separate accounts	2019-12-31	$0
Net investment gain/loss from pooled separate accounts	2019-12-31	$0
Net investment gain or loss from common/collective trusts	2019-12-31	$0
Net investment gain or loss from common/collective trusts	2019-12-31	$0
Net gain/loss from 103.12 investment entities	2019-12-31	$0
Net gain/loss from 103.12 investment entities	2019-12-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Assets. Invements in employer securities at beginning of year	2019-12-31	$0
Assets. Invements in employer securities at beginning of year	2019-12-31	$0
Assets. Value of employer real property at beginning of year	2019-12-31	$0
Contributions received in cash from employer	2019-12-31	$7,734
Contributions received in cash from employer	2019-12-31	$7,734
Employer contributions (assets) at end of year	2019-12-31	$368
Employer contributions (assets) at end of year	2019-12-31	$368
Employer contributions (assets) at beginning of year	2019-12-31	$0
Employer contributions (assets) at beginning of year	2019-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$43,941
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$43,941
Asset. Corporate debt instrument preferred debt at beginning of year	2019-12-31	$0
Asset. Corporate debt instrument preferred debt at beginning of year	2019-12-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2019-12-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2019-12-31	$0
Contract administrator fees	2019-12-31	$3,372
Contract administrator fees	2019-12-31	$3,372
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2019-12-31	Yes
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2019-12-31	Yes
Assets. Corporate common stocks other than exployer securities at beginning of year	2019-12-31	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2019-12-31	$0
Liabilities. Value of benefit claims payable at beginning of year	2019-12-31	$0
Liabilities. Value of benefit claims payable at beginning of year	2019-12-31	$0
Assets. Value of buildings and other operty used in plan operation at beginning of year	2019-12-31	$0
Assets. Value of buildings and other operty used in plan operation at beginning of year	2019-12-31	$0
Did the plan have assets held for investment	2019-12-31	Yes
Did the plan have assets held for investment	2019-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Liabilities. Value of acquisition indebtedness at beginning of year	2019-12-31	$0
Liabilities. Value of acquisition indebtedness at beginning of year	2019-12-31	$0
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Accountancy firm name	2019-12-31	BONADIO & CO., LLP
Accountancy firm name	2019-12-31	BONADIO & CO., LLP
Accountancy firm EIN	2019-12-31	161131146
Accountancy firm EIN	2019-12-31	161131146
2014 : ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2014 401k financial data
Total unrealized appreciation/depreciation of assets	2014-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$655
Total income from all sources (including contributions)	2014-12-31	$73,857
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$368,434
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$362,440
Expenses. Certain deemed distributions of participant loans	2014-12-31	$3,860
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$36,603
Value of total assets at end of year	2014-12-31	$400,338
Value of total assets at beginning of year	2014-12-31	$695,570
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$2,134
Total interest from all sources	2014-12-31	$684
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$200,000
If this is an individual account plan, was there a blackout period	2014-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$33,941
Participant contributions at end of year	2014-12-31	$16,439
Participant contributions at beginning of year	2014-12-31	$11,675
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2014-12-31	$655
Administrative expenses (other) incurred	2014-12-31	$325
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Value of net income/loss	2014-12-31	$-294,577
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$400,338
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$694,915
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-12-31	No
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Investment advisory and management fees	2014-12-31	$1,809
Value of interest in registered invesment companies (eg mutual funds) at end of year	2014-12-31	$374,877
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2014-12-31	$673,461
Interest on participant loans	2014-12-31	$642
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2014-12-31	$42
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-12-31	$9,022
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-12-31	$10,434
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2014-12-31	$36,570
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-12-31	No
Was there a failure to transmit to the plan any participant contributions	2014-12-31	No
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Contributions received in cash from employer	2014-12-31	$2,662
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$362,440
Did the plan have assets held for investment	2014-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2014-12-31	Disclaimer
Accountancy firm name	2014-12-31	EFP ROTENBERG LLP
Accountancy firm EIN	2014-12-31	264298079
2013 : ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2013 401k financial data
Total unrealized appreciation/depreciation of assets	2013-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$655
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$0
Total income from all sources (including contributions)	2013-12-31	$119,189
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$139,209
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$131,847
Expenses. Certain deemed distributions of participant loans	2013-12-31	$4,665
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$44,442
Value of total assets at end of year	2013-12-31	$695,570
Value of total assets at beginning of year	2013-12-31	$714,935
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$2,697
Total interest from all sources	2013-12-31	$504
Total dividends received (eg from common stock, registered investment company shares)	2013-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2013-12-31	No
Was this plan covered by a fidelity bond	2013-12-31	Yes
Value of fidelity bond cover	2013-12-31	$200,000
If this is an individual account plan, was there a blackout period	2013-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$36,757
Participant contributions at end of year	2013-12-31	$11,675
Participant contributions at beginning of year	2013-12-31	$13,707
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2013-12-31	$655
Administrative expenses (other) incurred	2013-12-31	$250
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Value of net income/loss	2013-12-31	$-20,020
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$694,915
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$714,935
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-12-31	No
Were any leases to which the plan was party in default or uncollectible	2013-12-31	No
Investment advisory and management fees	2013-12-31	$2,447
Value of interest in registered invesment companies (eg mutual funds) at end of year	2013-12-31	$673,461
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2013-12-31	$694,027
Interest on participant loans	2013-12-31	$458
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2013-12-31	$46
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2013-12-31	$10,434
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2013-12-31	$7,201
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2013-12-31	$74,243
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2013-12-31	No
Has the plan failed to provide any benefit when due under the plan	2013-12-31	No
Contributions received in cash from employer	2013-12-31	$7,685
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$131,847
Did the plan have assets held for investment	2013-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2013-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2013-12-31	Disclaimer
Accountancy firm name	2013-12-31	EFP ROTENBERG LLP
Accountancy firm EIN	2013-12-31	264298079
2012 : ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2012 401k financial data
Total unrealized appreciation/depreciation of assets	2012-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total income from all sources (including contributions)	2012-12-31	$152,236
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$76,819
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$66,436
Expenses. Certain deemed distributions of participant loans	2012-12-31	$7,289
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$73,156
Value of total assets at end of year	2012-12-31	$714,935
Value of total assets at beginning of year	2012-12-31	$639,515
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$3,094
Total interest from all sources	2012-12-31	$755
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$200,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$62,148
Participant contributions at end of year	2012-12-31	$13,707
Participant contributions at beginning of year	2012-12-31	$22,177
Administrative expenses (other) incurred	2012-12-31	$3,094
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net income/loss	2012-12-31	$75,417
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$714,935
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$639,515
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2012-12-31	$694,027
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2012-12-31	$612,686
Interest on participant loans	2012-12-31	$712
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2012-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2012-12-31	$3,081
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2012-12-31	$3,081
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2012-12-31	$43
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$7,201
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$1,571
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2012-12-31	$78,325
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Contributions received in cash from employer	2012-12-31	$11,008
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$66,436
Did the plan have assets held for investment	2012-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2012-12-31	Disclaimer
Accountancy firm name	2012-12-31	EFP ROTENBERG LLP
Accountancy firm EIN	2012-12-31	264298079
2011 : ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2011 401k financial data
Total unrealized appreciation/depreciation of assets	2011-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total income from all sources (including contributions)	2011-12-31	$72,831
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$43,597
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$39,441
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$74,252
Value of total assets at end of year	2011-12-31	$639,515
Value of total assets at beginning of year	2011-12-31	$610,281
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$4,156
Total interest from all sources	2011-12-31	$684
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Was this plan covered by a fidelity bond	2011-12-31	Yes
Value of fidelity bond cover	2011-12-31	$200,000
If this is an individual account plan, was there a blackout period	2011-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2011-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$63,761
Participant contributions at end of year	2011-12-31	$22,177
Participant contributions at beginning of year	2011-12-31	$19,760
Other income not declared elsewhere	2011-12-31	$221
Administrative expenses (other) incurred	2011-12-31	$4,156
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Value of net income/loss	2011-12-31	$29,234
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$639,515
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$610,281
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-12-31	No
Were any leases to which the plan was party in default or uncollectible	2011-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2011-12-31	$612,686
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2011-12-31	$590,521
Interest on participant loans	2011-12-31	$684
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2011-12-31	$3,081
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-12-31	$1,571
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2011-12-31	$-2,326
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-12-31	No
Was there a failure to transmit to the plan any participant contributions	2011-12-31	No
Has the plan failed to provide any benefit when due under the plan	2011-12-31	No
Contributions received in cash from employer	2011-12-31	$10,491
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$39,441
Did the plan have assets held for investment	2011-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2011-12-31	Disclaimer
Accountancy firm name	2011-12-31	EFP ROTENBERG LLP
Accountancy firm EIN	2011-12-31	264298079

Form 5500 Responses for ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN

2022: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	Yes
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	Yes
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2014: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401(K) PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

FIRST GREAT WEST LIFE INSURANCE & ANNUITY CO (National Association of Insurance Commissioners NAIC id number: 60214 )

Policy contract number

386232-01

Policy instance

Insurance contract or identification number	386232-01
Number of Individuals Covered	4
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $56
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28
Insurance broker organization code?	3
Insurance broker name	ROBERT URTZ

FIRST GREAT WEST LIFE INSURANCE & ANNUITY CO (National Association of Insurance Commissioners NAIC id number: 60214 )

Policy contract number

386232-01

Policy instance

Insurance contract or identification number	386232-01
Number of Individuals Covered	6
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $45
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ROBERT URTZ

FIRST GREAT WEST LIFE INSURANCE & ANNUITY CO (National Association of Insurance Commissioners NAIC id number: 60214 )

Policy contract number

386232-01

Policy instance

Insurance contract or identification number	386232-01
Number of Individuals Covered	7
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $28
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $14
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ROBERT URTZ

FIRST GREAT WEST LIFE INSURANCE & ANNUITY CO (National Association of Insurance Commissioners NAIC id number: 60214 )

Policy contract number

386232-01

Policy instance

Insurance contract or identification number	386232-01
Number of Individuals Covered	6
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No

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Company Name:	ST JOHNSVILLE A
Employer identification number (EIN):	201388111
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities