401k Plan data: SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA plan

SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA 401k Plan overview

Plan Name	SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA
Plan identification number	501

SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision

401k Sponsoring company profile

MESKWAKI BINGO CASINO HOTEL has sponsored the creation of one or more 401k plans.

Company Name: MESKWAKI BINGO CASINO HOTEL

Employer identification number (EIN): 421287035

NAIC Classification: 713200
NAIC Description: Gambling Industries

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2012-01-01 RUDY ROSSY
501 2012-01-01 RUDY ROSS
501 2012-01-01 RUDY ROSSY
501 2011-01-01 RUDY ROSSY
501 2011-01-01 RUDY ROSS
501 2011-01-01 RUDY ROSSY
501 2010-01-01 RAM DHANWADA RAM DHANWADA 2014-03-05

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2012-01-01	RUDY ROSSY
501	2012-01-01	RUDY ROSS
501	2012-01-01	RUDY ROSSY
501	2011-01-01	RUDY ROSSY
501	2011-01-01	RUDY ROSS
501	2011-01-01	RUDY ROSSY
501	2010-01-01	RAM DHANWADA	RAM DHANWADA	2014-03-05

Plan Statistics for SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA

401k plan membership statisitcs for SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA

Measure Date Value
2012: SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA 2012 401k membership
Total participants, beginning-of-year 2012-01-01 808
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 0
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 0
Total of all active and inactive participants 2012-01-01 0
2011: SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA 2011 401k membership
Total participants, beginning-of-year 2011-01-01 861
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 808
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 0
Total of all active and inactive participants 2011-01-01 808
2010: SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA 2010 401k membership
Total participants, beginning-of-year 2010-01-01 828
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 861
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 861

Measure	Date	Value
2012: SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA 2012 401k membership
Total participants, beginning-of-year	2012-01-01	808
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	0
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	0
Total of all active and inactive participants	2012-01-01	0
2011: SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA 2011 401k membership
Total participants, beginning-of-year	2011-01-01	861
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	808
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	0
Total of all active and inactive participants	2011-01-01	808
2010: SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA 2010 401k membership
Total participants, beginning-of-year	2010-01-01	828
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	861
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	861

Form 5500 Responses for SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA

2012: SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA 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	Yes
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 – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA 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 – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: SAC & FOX OF THE MISSISSIPPI IN IOWA CAFETERIA PLA 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX962613

Policy instance

Insurance contract or identification number	FLX962613
Number of Individuals Covered	805
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $18,427
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	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $116,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX962613

Policy instance

Insurance contract or identification number	FLX962613
Number of Individuals Covered	808
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $17,790
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	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $118,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX962613

Policy instance

Insurance contract or identification number	FLX962613
Number of Individuals Covered	861
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $18,191
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	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $121,517
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	MESKWAKI BINGO CASINO HOTEL
Employer identification number (EIN):	421287035
NAIC Classification:	713200
NAIC Description:	Gambling Industries