401k Plan data: OHIO VALLEY MANOR, INC. plan

OHIO VALLEY MANOR, INC. 401k Plan overview

Plan Name	OHIO VALLEY MANOR, INC.
Plan identification number	001

OHIO VALLEY MANOR, INC. 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

OHIO VALLEY MANOR has sponsored the creation of one or more 401k plans.

Company Name: OHIO VALLEY MANOR

Employer identification number (EIN): 310788268

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

Additional information about OHIO VALLEY MANOR

Jurisdiction of Incorporation: Ohio Secretary of State Business Services Division

Incorporation Date: 1968-10-18

Company Identification Number: 376701

Legal Registered Office Address: 5280 US RTS. 62-68
-
RIPLEY
United States of America (USA)
451679774

More information about OHIO VALLEY MANOR

Form 5500 Filing Information

Submission information for form 5500 for 401k plan OHIO VALLEY MANOR, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2017-01-01 GEORGE BALZ GEORGE BALZ 2018-03-27
001 2016-01-01 GEORGE BALZ GEORGE BALZ 2017-10-05
001 2015-01-01 GEORGE BALZ GEORGE BALZ 2016-07-22
001 2015-01-01 GEORGE BALZ GEORGE BALZ 2016-07-22
001 2014-01-01 GEORGE BALZ GEORGE BALZ 2015-08-24
001 2013-01-01 GEORGE BALZ GEORGE BALZ 2014-09-09
001 2012-01-01 GEORGE BALZ GEORGE BALZ 2013-09-09
001 2011-01-01 GEORGE BALZ GEORGE BALZ 2012-10-10
001 2009-01-01 GEORGE BALZ GEORGE BALZ 2010-10-12

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
001	2017-01-01	GEORGE BALZ	GEORGE BALZ	2018-03-27
001	2016-01-01	GEORGE BALZ	GEORGE BALZ	2017-10-05
001	2015-01-01	GEORGE BALZ	GEORGE BALZ	2016-07-22
001	2015-01-01	GEORGE BALZ	GEORGE BALZ	2016-07-22
001	2014-01-01	GEORGE BALZ	GEORGE BALZ	2015-08-24
001	2013-01-01	GEORGE BALZ	GEORGE BALZ	2014-09-09
001	2012-01-01	GEORGE BALZ	GEORGE BALZ	2013-09-09
001	2011-01-01	GEORGE BALZ	GEORGE BALZ	2012-10-10
001	2009-01-01	GEORGE BALZ	GEORGE BALZ	2010-10-12

Plan Statistics for OHIO VALLEY MANOR, INC.

401k plan membership statisitcs for OHIO VALLEY MANOR, INC.

Measure Date Value
2017: OHIO VALLEY MANOR, INC. 2017 401k membership
Total participants, beginning-of-year 2017-01-01 203
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 0
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 0
Number of participants with account balances 2017-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 0
2016: OHIO VALLEY MANOR, INC. 2016 401k membership
Total participants, beginning-of-year 2016-01-01 200
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 179
Number of other retired or separated participants entitled to future benefits 2016-01-01 13
Total of all active and inactive participants 2016-01-01 192
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 192
Number of participants with account balances 2016-01-01 87
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0
2015: OHIO VALLEY MANOR, INC. 2015 401k membership
Total participants, beginning-of-year 2015-01-01 206
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 173
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 15
Total of all active and inactive participants 2015-01-01 188
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 188
Number of participants with account balances 2015-01-01 85
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 0
2014: OHIO VALLEY MANOR, INC. 2014 401k membership
Total participants, beginning-of-year 2014-01-01 216
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 184
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 18
Total of all active and inactive participants 2014-01-01 202
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 202
Number of participants with account balances 2014-01-01 93
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: OHIO VALLEY MANOR, INC. 2013 401k membership
Total participants, beginning-of-year 2013-01-01 200
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 195
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 15
Total of all active and inactive participants 2013-01-01 210
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 210
Number of participants with account balances 2013-01-01 97
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 14
2012: OHIO VALLEY MANOR, INC. 2012 401k membership
Total participants, beginning-of-year 2012-01-01 192
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 174
Number of retired or separated participants receiving benefits 2012-01-01 15
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 189
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 189
Number of participants with account balances 2012-01-01 89
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 1
2011: OHIO VALLEY MANOR, INC. 2011 401k membership
Total participants, beginning-of-year 2011-01-01 202
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 166
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 17
Total of all active and inactive participants 2011-01-01 183
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 183
Number of participants with account balances 2011-01-01 95
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 4
2009: OHIO VALLEY MANOR, INC. 2009 401k membership
Total participants, beginning-of-year 2009-01-01 192
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 170
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 17
Total of all active and inactive participants 2009-01-01 187
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 187
Number of participants with account balances 2009-01-01 94
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 13

Measure	Date	Value
2017: OHIO VALLEY MANOR, INC. 2017 401k membership
Total participants, beginning-of-year	2017-01-01	203
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	0
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	0
Number of participants with account balances	2017-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	0
2016: OHIO VALLEY MANOR, INC. 2016 401k membership
Total participants, beginning-of-year	2016-01-01	200
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	179
Number of other retired or separated participants entitled to future benefits	2016-01-01	13
Total of all active and inactive participants	2016-01-01	192
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	192
Number of participants with account balances	2016-01-01	87
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0
2015: OHIO VALLEY MANOR, INC. 2015 401k membership
Total participants, beginning-of-year	2015-01-01	206
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	173
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	15
Total of all active and inactive participants	2015-01-01	188
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	188
Number of participants with account balances	2015-01-01	85
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	0
2014: OHIO VALLEY MANOR, INC. 2014 401k membership
Total participants, beginning-of-year	2014-01-01	216
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	184
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	18
Total of all active and inactive participants	2014-01-01	202
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	202
Number of participants with account balances	2014-01-01	93
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: OHIO VALLEY MANOR, INC. 2013 401k membership
Total participants, beginning-of-year	2013-01-01	200
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	195
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	15
Total of all active and inactive participants	2013-01-01	210
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	210
Number of participants with account balances	2013-01-01	97
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	14
2012: OHIO VALLEY MANOR, INC. 2012 401k membership
Total participants, beginning-of-year	2012-01-01	192
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	174
Number of retired or separated participants receiving benefits	2012-01-01	15
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	189
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	189
Number of participants with account balances	2012-01-01	89
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	1
2011: OHIO VALLEY MANOR, INC. 2011 401k membership
Total participants, beginning-of-year	2011-01-01	202
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	166
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	17
Total of all active and inactive participants	2011-01-01	183
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	183
Number of participants with account balances	2011-01-01	95
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	4
2009: OHIO VALLEY MANOR, INC. 2009 401k membership
Total participants, beginning-of-year	2009-01-01	192
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	170
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	17
Total of all active and inactive participants	2009-01-01	187
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	187
Number of participants with account balances	2009-01-01	94
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	13

Financial Data on OHIO VALLEY MANOR, INC.

Measure	Date	Value
2017 : OHIO VALLEY MANOR, INC. 2017 401k financial data
Total unrealized appreciation/depreciation of assets	2017-06-30	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-06-30	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-06-30	$0
Total income from all sources (including contributions)	2017-06-30	$180,124
Total loss/gain on sale of assets	2017-06-30	$0
Total of all expenses incurred	2017-06-30	$2,684,273
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-06-30	$2,682,911
Value of total corrective distributions	2017-06-30	$942
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-06-30	$31,610
Value of total assets at end of year	2017-06-30	$0
Value of total assets at beginning of year	2017-06-30	$2,504,149
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-06-30	$420
Total interest from all sources	2017-06-30	$0
Total dividends received (eg from common stock, registered investment company shares)	2017-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-06-30	Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan	2017-06-30	$0
Administrative expenses professional fees incurred	2017-06-30	$420
Was this plan covered by a fidelity bond	2017-06-30	Yes
Value of fidelity bond cover	2017-06-30	$500,000
If this is an individual account plan, was there a blackout period	2017-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2017-06-30	No
Contributions received from participants	2017-06-30	$24,818
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-06-30	No
Value of net income/loss	2017-06-30	$-2,504,149
Value of net assets at end of year (total assets less liabilities)	2017-06-30	$0
Value of net assets at beginning of year (total assets less liabilities)	2017-06-30	$2,504,149
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-06-30	No
Were any leases to which the plan was party in default or uncollectible	2017-06-30	No
Value of interest in pooled separate accounts at end of year	2017-06-30	$0
Value of interest in pooled separate accounts at beginning of year	2017-06-30	$2,504,149
Net investment gain/loss from pooled separate accounts	2017-06-30	$148,514
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-06-30	No
Was there a failure to transmit to the plan any participant contributions	2017-06-30	No
Has the plan failed to provide any benefit when due under the plan	2017-06-30	No
Contributions received in cash from employer	2017-06-30	$6,792
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-06-30	$2,682,911
Did the plan have assets held for investment	2017-06-30	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	2017-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-06-30	Yes
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2017-06-30	Disclaimer
Accountancy firm name	2017-06-30	PLANTE AND MORAN
Accountancy firm EIN	2017-06-30	381357951
2016 : OHIO VALLEY MANOR, INC. 2016 401k financial data
Total unrealized appreciation/depreciation of assets	2016-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$0
Total income from all sources (including contributions)	2016-12-31	$287,748
Total loss/gain on sale of assets	2016-12-31	$0
Total of all expenses incurred	2016-12-31	$239,333
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$239,333
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$143,086
Value of total assets at end of year	2016-12-31	$2,504,149
Value of total assets at beginning of year	2016-12-31	$2,455,734
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$0
Total interest from all sources	2016-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2016-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-12-31	No
Was this plan covered by a fidelity bond	2016-12-31	Yes
Value of fidelity bond cover	2016-12-31	$500,000
If this is an individual account plan, was there a blackout period	2016-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2016-12-31	No
Contributions received from participants	2016-12-31	$113,893
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Value of net income/loss	2016-12-31	$48,415
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$2,504,149
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$2,455,734
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-12-31	No
Were any leases to which the plan was party in default or uncollectible	2016-12-31	No
Value of interest in pooled separate accounts at end of year	2016-12-31	$2,504,149
Value of interest in pooled separate accounts at beginning of year	2016-12-31	$2,455,734
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2016-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2016-12-31	$0
Net investment gain/loss from pooled separate accounts	2016-12-31	$144,662
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-12-31	No
Was there a failure to transmit to the plan any participant contributions	2016-12-31	No
Has the plan failed to provide any benefit when due under the plan	2016-12-31	No
Contributions received in cash from employer	2016-12-31	$29,193
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$239,333
Did the plan have assets held for investment	2016-12-31	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	2016-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-12-31	No
2015 : OHIO VALLEY MANOR, INC. 2015 401k financial data
Total unrealized appreciation/depreciation of assets	2015-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total income from all sources (including contributions)	2015-12-31	$111,461
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$281,323
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$280,758
Value of total corrective distributions	2015-12-31	$565
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$139,544
Value of total assets at end of year	2015-12-31	$2,455,734
Value of total assets at beginning of year	2015-12-31	$2,625,596
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$0
Total interest from all sources	2015-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$500,000
If this is an individual account plan, was there a blackout period	2015-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$109,458
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Value of net income/loss	2015-12-31	$-169,862
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$2,455,734
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$2,625,596
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-12-31	No
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Value of interest in pooled separate accounts at end of year	2015-12-31	$2,455,734
Value of interest in pooled separate accounts at beginning of year	2015-12-31	$2,625,596
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2015-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2015-12-31	$0
Net investment gain/loss from pooled separate accounts	2015-12-31	$-28,083
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-12-31	No
Was there a failure to transmit to the plan any participant contributions	2015-12-31	No
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Contributions received in cash from employer	2015-12-31	$30,086
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$280,758
Did the plan have assets held for investment	2015-12-31	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	2015-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2015-12-31	Disclaimer
Accountancy firm name	2015-12-31	PLANTE AND MORAN
Accountancy firm EIN	2015-12-31	381357951
2014 : OHIO VALLEY MANOR, INC. 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	$0
Total income from all sources (including contributions)	2014-12-31	$264,111
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$372,834
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$372,221
Value of total corrective distributions	2014-12-31	$613
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$134,877
Value of total assets at end of year	2014-12-31	$2,625,596
Value of total assets at beginning of year	2014-12-31	$2,734,319
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$0
Total interest from all sources	2014-12-31	$0
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	$500,000
If this is an individual account plan, was there a blackout period	2014-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$105,655
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	$-108,723
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$2,625,596
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$2,734,319
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
Value of interest in pooled separate accounts at end of year	2014-12-31	$2,625,596
Value of interest in pooled separate accounts at beginning of year	2014-12-31	$2,734,319
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-12-31	$0
Net investment gain/loss from pooled separate accounts	2014-12-31	$129,234
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	$29,222
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$372,221
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	PLANTE AND MORAN PLLC
Accountancy firm EIN	2014-12-31	381357951
2013 : OHIO VALLEY MANOR, INC. 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	$0
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	$566,831
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$25,756
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$25,756
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$143,513
Value of total assets at end of year	2013-12-31	$2,734,319
Value of total assets at beginning of year	2013-12-31	$2,193,244
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$0
Total interest from all sources	2013-12-31	$0
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	$500,000
If this is an individual account plan, was there a blackout period	2013-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$116,406
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	$541,075
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$2,734,319
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$2,193,244
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
Value of interest in pooled separate accounts at end of year	2013-12-31	$2,734,319
Value of interest in pooled separate accounts at beginning of year	2013-12-31	$2,193,244
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2013-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2013-12-31	$0
Net investment gain/loss from pooled separate accounts	2013-12-31	$423,318
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	No
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	$27,107
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$25,756
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	PLANTE AND MORAN
Accountancy firm EIN	2013-12-31	381357951
2012 : OHIO VALLEY MANOR, INC. 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	$409,496
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$187,800
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$173,377
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$132,499
Value of total assets at end of year	2012-12-31	$2,193,244
Value of total assets at beginning of year	2012-12-31	$1,971,548
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$14,423
Total interest from all sources	2012-12-31	$0
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
Administrative expenses professional fees incurred	2012-12-31	$14,423
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$500,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$107,671
Participant contributions at end of year	2012-12-31	$0
Participant contributions at beginning of year	2012-12-31	$4,136
Income. Received or receivable in cash from other sources (including rollovers)	2012-12-31	$2,748
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	$221,696
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$2,193,244
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$1,971,548
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 pooled separate accounts at end of year	2012-12-31	$2,193,244
Value of interest in pooled separate accounts at beginning of year	2012-12-31	$1,966,450
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$0
Net investment gain/loss from pooled separate accounts	2012-12-31	$276,997
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	No
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	$22,080
Employer contributions (assets) at end of year	2012-12-31	$0
Employer contributions (assets) at beginning of year	2012-12-31	$962
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$173,377
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	PLANTE AND MORAN
Accountancy firm EIN	2012-12-31	381357951
2011 : OHIO VALLEY MANOR, INC. 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	$139,527
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$174,941
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$154,424
Value of total corrective distributions	2011-12-31	$499
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$190,048
Value of total assets at end of year	2011-12-31	$1,971,548
Value of total assets at beginning of year	2011-12-31	$2,006,962
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$20,018
Total interest from all sources	2011-12-31	$0
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	$500,000
If this is an individual account plan, was there a blackout period	2011-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$126,097
Participant contributions at end of year	2011-12-31	$4,136
Participant contributions at beginning of year	2011-12-31	$5,278
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	$-35,414
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$1,971,548
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$2,006,962
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 pooled separate accounts at end of year	2011-12-31	$1,966,450
Value of interest in pooled separate accounts at beginning of year	2011-12-31	$1,998,203
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2011-12-31	$0
Net investment gain/loss from pooled separate accounts	2011-12-31	$-50,521
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	$63,951
Employer contributions (assets) at end of year	2011-12-31	$962
Employer contributions (assets) at beginning of year	2011-12-31	$3,481
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$154,424
Contract administrator fees	2011-12-31	$20,018
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	PLANTE AND MORAN
Accountancy firm EIN	2011-12-31	381357951
2010 : OHIO VALLEY MANOR, INC. 2010 401k financial data
Total unrealized appreciation/depreciation of assets	2010-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$0
Total income from all sources (including contributions)	2010-12-31	$484,909
Total loss/gain on sale of assets	2010-12-31	$0
Total of all expenses incurred	2010-12-31	$133,746
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$115,314
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$239,931
Value of total assets at end of year	2010-12-31	$2,006,962
Value of total assets at beginning of year	2010-12-31	$1,655,799
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$18,432
Total interest from all sources	2010-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$500,000
If this is an individual account plan, was there a blackout period	2010-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$147,169
Participant contributions at end of year	2010-12-31	$5,278
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Value of net income/loss	2010-12-31	$351,163
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$2,006,962
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$1,655,799
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Value of interest in pooled separate accounts at end of year	2010-12-31	$1,998,203
Value of interest in pooled separate accounts at beginning of year	2010-12-31	$1,655,799
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$0
Net investment gain/loss from pooled separate accounts	2010-12-31	$244,978
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2010-12-31	No
Was there a failure to transmit to the plan any participant contributions	2010-12-31	No
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Contributions received in cash from employer	2010-12-31	$92,762
Employer contributions (assets) at end of year	2010-12-31	$3,481
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$115,314
Contract administrator fees	2010-12-31	$18,432
Did the plan have assets held for investment	2010-12-31	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	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2010-12-31	Disclaimer
Accountancy firm name	2010-12-31	PLANTE AND MORAN
Accountancy firm EIN	2010-12-31	381357951

Form 5500 Responses for OHIO VALLEY MANOR, INC.

2017: OHIO VALLEY MANOR, INC. 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	Yes
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: OHIO VALLEY MANOR, INC. 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: OHIO VALLEY MANOR, INC. 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: OHIO VALLEY MANOR, INC. 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: OHIO VALLEY MANOR, INC. 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: OHIO VALLEY MANOR, INC. 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: OHIO VALLEY MANOR, INC. 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
2009: OHIO VALLEY MANOR, INC. 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

70742

Policy instance

Insurance contract or identification number	70742
Number of Individuals Covered	0
Insurance policy start date	2017-01-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $3,478
Total amount of fees paid to insurance company	USD $184
Are there contracts with allocated funds for individual policies?	0
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?	No
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
Commission paid to Insurance Broker	USD $3,478
Insurance broker organization code?	3
Amount paid for insurance broker fees	184
Additional information about fees paid to insurance broker	TPA FEE
Insurance broker name	TRI-STATE PLAN ADMINISTRATION, INC.

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

70742

Policy instance

Insurance contract or identification number	70742
Number of Individuals Covered	101
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,561
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?	No
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 $9,561
Insurance broker organization code?	3
Insurance broker name	RAYMOND JAMES INSURANCE GROUP, INC.

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

70742

Policy instance

Insurance contract or identification number	70742
Number of Individuals Covered	108
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,785
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?	No
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 $9,785
Insurance broker organization code?	3
Insurance broker name	RAYMOND JAMES INSURANCE GROUP, INC.

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

70742

Policy instance

Insurance contract or identification number	70742
Number of Individuals Covered	114
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $8,961
Total amount of fees paid to insurance company	USD $91
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?	No
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 $4,884
Insurance broker organization code?	3
Amount paid for insurance broker fees	91
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	TRI-STATE PLAN ADMINISTRATION

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

70742

Policy instance

Insurance contract or identification number	70742
Number of Individuals Covered	103
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $11,340
Total amount of fees paid to insurance company	USD $1,051
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?	No
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
Commission paid to Insurance Broker	USD $5,670
Insurance broker organization code?	3
Amount paid for insurance broker fees	1051
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	TRI-STATE PLAN ADMINISTRATION

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

70742

Policy instance

Insurance contract or identification number	70742
Number of Individuals Covered	109
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $12,088
Total amount of fees paid to insurance company	USD $1,160
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?	No
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

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

70742

Policy instance

Insurance contract or identification number	70742
Number of Individuals Covered	101
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $10,432
Total amount of fees paid to insurance company	USD $692
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?	No
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
Commission paid to Insurance Broker	USD $5,216
Insurance broker organization code?	3
Amount paid for insurance broker fees	692
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	TRI-STATE PLAN ADMINISTRATION

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Company Name:	OHIO VALLEY MANOR
Employer identification number (EIN):	310788268
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Jurisdiction of Incorporation:	Ohio Secretary of State Business Services Division
Incorporation Date:	1968-10-18
Company Identification Number:	376701
Legal Registered Office Address:	5280 US RTS. 62-68 - RIPLEY United States of America (USA) 451679774