401k Plan data: COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN plan

COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN 401k Plan overview

Plan Name	COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN
Plan identification number	002

COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT 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

COMMUNITY BLOOD BANK OF LCMS has sponsored the creation of one or more 401k plans.

Company Name: COMMUNITY BLOOD BANK OF LCMS

Employer identification number (EIN): 470524449

NAIC Classification: 621900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2012-07-01 TINA LINNE JOHN BUSKE 2014-02-05
002 2011-07-01 CANDACE THOMAZIN
002 2010-07-01 CANDACE THOMAZIN 2011-08-26

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
002	2012-07-01	TINA LINNE		JOHN BUSKE	2014-02-05
002	2011-07-01	CANDACE THOMAZIN
002	2010-07-01	CANDACE THOMAZIN	2011-08-26

Plan Statistics for COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN

401k plan membership statisitcs for COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN

Measure Date Value
2012: COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 122
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 0
Number of retired or separated participants receiving benefits 2012-07-01 0
Number of other retired or separated participants entitled to future benefits 2012-07-01 0
Total of all active and inactive participants 2012-07-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-07-01 0
Total participants 2012-07-01 0
Number of participants with account balances 2012-07-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-07-01 4
2011: COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 121
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 82
Number of retired or separated participants receiving benefits 2011-07-01 0
Number of other retired or separated participants entitled to future benefits 2011-07-01 35
Total of all active and inactive participants 2011-07-01 117
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-07-01 0
Total participants 2011-07-01 117
Number of participants with account balances 2011-07-01 110
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-07-01 5

Measure	Date	Value
2012: COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	122
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	0
Number of retired or separated participants receiving benefits	2012-07-01	0
Number of other retired or separated participants entitled to future benefits	2012-07-01	0
Total of all active and inactive participants	2012-07-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-07-01	0
Total participants	2012-07-01	0
Number of participants with account balances	2012-07-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-07-01	4
2011: COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	121
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	82
Number of retired or separated participants receiving benefits	2011-07-01	0
Number of other retired or separated participants entitled to future benefits	2011-07-01	35
Total of all active and inactive participants	2011-07-01	117
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-07-01	0
Total participants	2011-07-01	117
Number of participants with account balances	2011-07-01	110
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-07-01	5

Financial Data on COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN

Measure	Date	Value
2013 : COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN 2013 401k financial data
Total transfer of assets from this plan	2013-06-03	$3,226,675
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-06-03	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-06-03	$0
Total income from all sources (including contributions)	2013-06-03	$770,599
Total of all expenses incurred	2013-06-03	$1,689,993
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-06-03	$1,696,050
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-06-03	$190,765
Value of total assets at end of year	2013-06-03	$0
Value of total assets at beginning of year	2013-06-03	$4,146,069
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-06-03	$-6,057
Total interest from all sources	2013-06-03	$17,104
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2013-06-03	No
Was this plan covered by a fidelity bond	2013-06-03	Yes
Value of fidelity bond cover	2013-06-03	$500,000
If this is an individual account plan, was there a blackout period	2013-06-03	No
Were there any nonexempt tranactions with any party-in-interest	2013-06-03	No
Contributions received from participants	2013-06-03	$190,015
Participant contributions at beginning of year	2013-06-03	$4,920
Participant contributions at beginning of year	2013-06-03	$8,070
Income. Received or receivable in cash from other sources (including rollovers)	2013-06-03	$750
Administrative expenses (other) incurred	2013-06-03	$-6,057
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-06-03	No
Value of net income/loss	2013-06-03	$-919,394
Value of net assets at end of year (total assets less liabilities)	2013-06-03	$0
Value of net assets at beginning of year (total assets less liabilities)	2013-06-03	$4,146,069
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-06-03	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-06-03	No
Were any leases to which the plan was party in default or uncollectible	2013-06-03	No
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2013-06-03	$489,079
Value of interest in pooled separate accounts at beginning of year	2013-06-03	$3,406,473
Interest on participant loans	2013-06-03	$183
Interest earned on other investments	2013-06-03	$16,921
Net investment gain/loss from pooled separate accounts	2013-06-03	$562,730
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-06-03	No
Was there a failure to transmit to the plan any participant contributions	2013-06-03	No
Has the plan failed to provide any benefit when due under the plan	2013-06-03	No
Employer contributions (assets) at beginning of year	2013-06-03	$237,527
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-06-03	$1,696,050
Did the plan have assets held for investment	2013-06-03	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	2013-06-03	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-06-03	Yes
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2013-06-03	Yes
Opinion of an independent qualified public accountant for this plan	2013-06-03	Disclaimer
Accountancy firm name	2013-06-03	GRAFTON & ASSOCIATES, P.C.
Accountancy firm EIN	2013-06-03	470760951
2012 : COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN 2012 401k financial data
Unrealized appreciation/depreciation of real estate assets	2012-06-30	$0
Unrealized appreciation/depreciation of other (non real estate) assets	2012-06-30	$0
Total unrealized appreciation/depreciation of assets	2012-06-30	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-06-30	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-06-30	$0
Expenses. Interest paid	2012-06-30	$0
Amount of participant contributions which was failed to transmit to the plan within the time period described in 29 CFR 251.3-102	2012-06-30	$0
Total income from all sources (including contributions)	2012-06-30	$771,021
Total loss/gain on sale of assets	2012-06-30	$0
Total of all expenses incurred	2012-06-30	$229,802
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-06-30	$229,802
Expenses. Certain deemed distributions of participant loans	2012-06-30	$0
Value of total corrective distributions	2012-06-30	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-06-30	$727,480
Value of total assets at end of year	2012-06-30	$4,146,069
Value of total assets at beginning of year	2012-06-30	$3,604,850
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-06-30	$0
Total income from rents	2012-06-30	$0
Total interest from all sources	2012-06-30	$17,887
Total dividends received (eg from common stock, registered investment company shares)	2012-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-06-30	No
Total dividends received from registered investment company shares (eg mutual funds)	2012-06-30	$0
Assets. Real estate other than employer real property at end of year	2012-06-30	$0
Assets. Real estate other than employer real property at beginning of year	2012-06-30	$0
Administrative expenses professional fees incurred	2012-06-30	$0
Assets. Corporate prefeered stocks other than exployer securities at end of year	2012-06-30	$0
Assets. Corporate prefeered stocks other than exployer securities at beginning of year	2012-06-30	$0
Was this plan covered by a fidelity bond	2012-06-30	Yes
Value of fidelity bond cover	2012-06-30	$500,000
If this is an individual account plan, was there a blackout period	2012-06-30	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-06-30	$0
Were there any nonexempt tranactions with any party-in-interest	2012-06-30	No
Contributions received from participants	2012-06-30	$236,896
Participant contributions at end of year	2012-06-30	$4,920
Participant contributions at beginning of year	2012-06-30	$8,432
Participant contributions at end of year	2012-06-30	$8,070
Participant contributions at beginning of year	2012-06-30	$0
Assets. Other investments not covered elsewhere at end of year	2012-06-30	$0
Assets. Other investments not covered elsewhere at beginning of year	2012-06-30	$0
Income. Received or receivable in cash from other sources (including rollovers)	2012-06-30	$29,099
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2012-06-30	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2012-06-30	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2012-06-30	$0
Assets. Loans (other than to participants) at end of year	2012-06-30	$0
Assets. Loans (other than to participants) at beginning of year	2012-06-30	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2012-06-30	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2012-06-30	$0
Other income not declared elsewhere	2012-06-30	$0
Administrative expenses (other) incurred	2012-06-30	$0
Liabilities. Value of operating payables at end of year	2012-06-30	$0
Liabilities. Value of operating payables at beginning of year	2012-06-30	$0
Total non interest bearing cash at end of year	2012-06-30	$0
Total non interest bearing cash at beginning of year	2012-06-30	$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	2012-06-30	No
Income. Non cash contributions	2012-06-30	$0
Value of net income/loss	2012-06-30	$541,219
Value of net assets at end of year (total assets less liabilities)	2012-06-30	$4,146,069
Value of net assets at beginning of year (total assets less liabilities)	2012-06-30	$3,604,850
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-06-30	No
Were any leases to which the plan was party in default or uncollectible	2012-06-30	No
Assets. partnership/joint venture interests at end of year	2012-06-30	$0
Assets. partnership/joint venture interests at beginning of year	2012-06-30	$0
Investment advisory and management fees	2012-06-30	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2012-06-30	$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2012-06-30	$0
Value of interest in pooled separate accounts at end of year	2012-06-30	$3,406,473
Value of interest in pooled separate accounts at beginning of year	2012-06-30	$3,117,298
Interest on participant loans	2012-06-30	$406
Income. Interest from loans (other than to participants)	2012-06-30	$0
Interest earned on other investments	2012-06-30	$17,481
Income. Interest from US Government securities	2012-06-30	$0
Income. Interest from corporate debt instruments	2012-06-30	$0
Value of interest in master investment trust accounts at end of year	2012-06-30	$0
Value of interest in master investment trust accounts at beginning of year	2012-06-30	$0
Value of interest in common/collective trusts at end of year	2012-06-30	$0
Value of interest in common/collective trusts at beginning of year	2012-06-30	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2012-06-30	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2012-06-30	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2012-06-30	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2012-06-30	$0
Assets. Value of investments in 103.12 investment entities at end of year	2012-06-30	$0
Assets. Value of investments in 103.12 investment entities at beginning of year	2012-06-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-06-30	$489,079
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-06-30	$479,120
Expenses. Payments to insurance carriers foe the provision of benefits	2012-06-30	$0
Asset value of US Government securities at end of year	2012-06-30	$0
Asset value of US Government securities at beginning of year	2012-06-30	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2012-06-30	$0
Net investment gain/loss from pooled separate accounts	2012-06-30	$25,654
Net investment gain or loss from common/collective trusts	2012-06-30	$0
Net gain/loss from 103.12 investment entities	2012-06-30	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-06-30	No
Was there a failure to transmit to the plan any participant contributions	2012-06-30	No
Has the plan failed to provide any benefit when due under the plan	2012-06-30	No
Assets. Invements in employer securities at end of year	2012-06-30	$0
Assets. Invements in employer securities at beginning of year	2012-06-30	$0
Assets. Value of employer real property at end of year	2012-06-30	$0
Assets. Value of employer real property at beginning of year	2012-06-30	$0
Contributions received in cash from employer	2012-06-30	$461,485
Employer contributions (assets) at end of year	2012-06-30	$237,527
Employer contributions (assets) at beginning of year	2012-06-30	$0
Income. Dividends from preferred stock	2012-06-30	$0
Income. Dividends from common stock	2012-06-30	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-06-30	$229,802
Asset. Corporate debt instrument preferred debt at end of year	2012-06-30	$0
Asset. Corporate debt instrument preferred debt at beginning of year	2012-06-30	$0
Asset. Corporate debt instrument debt (other) at end of year	2012-06-30	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2012-06-30	$0
Contract administrator fees	2012-06-30	$0
Assets. Corporate common stocks other than exployer securities at end of year	2012-06-30	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2012-06-30	$0
Liabilities. Value of benefit claims payable at end of year	2012-06-30	$0
Liabilities. Value of benefit claims payable at beginning of year	2012-06-30	$0
Assets. Value of buildings and other operty used in plan operation at end of year	2012-06-30	$0
Assets. Value of buildings and other operty used in plan operation at beginning of year	2012-06-30	$0
Did the plan have assets held for investment	2012-06-30	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	2012-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-06-30	No
Aggregate proceeds on sale of assets	2012-06-30	$0
Aggregate carrying amount (costs) on sale of assets	2012-06-30	$0
Liabilities. Value of acquisition indebtedness at end of year	2012-06-30	$0
Liabilities. Value of acquisition indebtedness at beginning of year	2012-06-30	$0
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2012-06-30	Disclaimer
Accountancy firm name	2012-06-30	GRAFTON & ASSOCIATES, P.C.
Accountancy firm EIN	2012-06-30	470760951

Form 5500 Responses for COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN

2012: COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	This submission is the final filing	Yes
2012-07-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2011: COMMUNITY BLOOD BANK OF THE LCMS RETIREMENT PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Submission has been amended	No
2011-07-01	This submission is the final filing	No
2011-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-07-01	Plan is a collectively bargained plan	No
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

260801

Policy instance

Insurance contract or identification number	260801
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-03
Total amount of commissions paid to insurance broker	USD $8,631
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,631
Insurance broker organization code?	3
Insurance broker name	MIDLANDS FINANCIAL BENEFITS

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

260801

Policy instance

Insurance contract or identification number	260801
Number of Individuals Covered	110
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $8,486
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	1
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

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Company Name:	COMMUNITY BLOOD BANK OF LCMS
Employer identification number (EIN):	470524449
NAIC Classification:	621900