401k Plan data: JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN plan

JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN 401k Plan overview

Plan Name	JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN
Plan identification number	001

JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
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

JOHN B. GOOLSBY, DMD, INC. has sponsored the creation of one or more 401k plans.

Company Name: JOHN B. GOOLSBY, DMD, INC.

Employer identification number (EIN): 550813168

NAIC Classification: 621210
NAIC Description: Offices of Dentists

Form 5500 Filing Information

Submission information for form 5500 for 401k plan JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2013-01-01 JOHN GOOLSBY JOHN GOOLSBY 2013-08-18
001 2012-01-01 JOHN GOOLSBY
001 2011-01-01 JOHN GOOLSBY
001 2010-01-01 JOHN GOOLSBY
001 2009-01-01 JOHN B GOOLSBY

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
001	2013-01-01	JOHN GOOLSBY	JOHN GOOLSBY	2013-08-18
001	2012-01-01	JOHN GOOLSBY
001	2011-01-01	JOHN GOOLSBY
001	2010-01-01	JOHN GOOLSBY
001	2009-01-01	JOHN B GOOLSBY

Financial Data on JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN

Measure	Date	Value
2013 : JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN 2013 401k financial data
Transfers to/from the plan	2013-02-28	$0
Total income from all sources	2013-02-28	$11,350
Expenses. Total of all expenses incurred	2013-02-28	$163,917
Benefits paid (including direct rollovers)	2013-02-28	$163,917
Total plan assets at end of year	2013-02-28	$0
Total plan assets at beginning of year	2013-02-28	$152,567
Value of fidelity bond covering the plan	2013-02-28	$25,000
Total contributions received or receivable from participants	2013-02-28	$0
Expenses. Other expenses not covered elsewhere	2013-02-28	$0
Contributions received from other sources (not participants or employers)	2013-02-28	$0
Other income received	2013-02-28	$11,350
Net income (gross income less expenses)	2013-02-28	$-152,567
Net plan assets at end of year (total assets less liabilities)	2013-02-28	$0
Net plan assets at beginning of year (total assets less liabilities)	2013-02-28	$152,567
Total contributions received or receivable from employer(s)	2013-02-28	$0
Value of certain deemed distributions of participant loans	2013-02-28	$0
Value of corrective distributions	2013-02-28	$0
Funding deficiency by the employer to the plan for this plan year	2013-02-28	$0
Minimum employer required contribution for this plan year	2013-02-28	$0
Amount contributed by the employer to the plan for this plan year	2013-02-28	$0
2012 : JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN 2012 401k financial data
Transfers to/from the plan	2012-12-31	$0
Total income from all sources	2012-12-31	$21,828
Expenses. Total of all expenses incurred	2012-12-31	$1,278
Benefits paid (including direct rollovers)	2012-12-31	$1,178
Total plan assets at end of year	2012-12-31	$152,567
Total plan assets at beginning of year	2012-12-31	$132,017
Value of fidelity bond covering the plan	2012-12-31	$25,000
Total contributions received or receivable from participants	2012-12-31	$9,080
Expenses. Other expenses not covered elsewhere	2012-12-31	$100
Contributions received from other sources (not participants or employers)	2012-12-31	$0
Other income received	2012-12-31	$6,570
Net income (gross income less expenses)	2012-12-31	$20,550
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$152,567
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$132,017
Total contributions received or receivable from employer(s)	2012-12-31	$6,178
Value of certain deemed distributions of participant loans	2012-12-31	$0
Value of corrective distributions	2012-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2012-12-31	$0
Minimum employer required contribution for this plan year	2012-12-31	$0
Amount contributed by the employer to the plan for this plan year	2012-12-31	$0
2011 : JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN 2011 401k financial data
Transfers to/from the plan	2011-12-31	$0
Total income from all sources	2011-12-31	$37,109
Expenses. Total of all expenses incurred	2011-12-31	$1,376
Benefits paid (including direct rollovers)	2011-12-31	$1,270
Total plan assets at end of year	2011-12-31	$132,017
Total plan assets at beginning of year	2011-12-31	$96,284
Value of fidelity bond covering the plan	2011-12-31	$25,000
Total contributions received or receivable from participants	2011-12-31	$28,580
Expenses. Other expenses not covered elsewhere	2011-12-31	$106
Contributions received from other sources (not participants or employers)	2011-12-31	$0
Other income received	2011-12-31	$2,441
Net income (gross income less expenses)	2011-12-31	$35,733
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$132,017
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$96,284
Assets. Value of participant loans	2011-12-31	$0
Total contributions received or receivable from employer(s)	2011-12-31	$6,088
Value of certain deemed distributions of participant loans	2011-12-31	$0
Value of corrective distributions	2011-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2011-12-31	$0
Minimum employer required contribution for this plan year	2011-12-31	$0
Amount contributed by the employer to the plan for this plan year	2011-12-31	$0
2010 : JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN 2010 401k financial data
Transfers to/from the plan	2010-12-31	$0
Total income from all sources	2010-12-31	$22,369
Expenses. Total of all expenses incurred	2010-12-31	$485
Benefits paid (including direct rollovers)	2010-12-31	$360
Total plan assets at end of year	2010-12-31	$96,284
Total plan assets at beginning of year	2010-12-31	$74,400
Value of fidelity bond covering the plan	2010-12-31	$25,000
Total contributions received or receivable from participants	2010-12-31	$12,840
Expenses. Other expenses not covered elsewhere	2010-12-31	$125
Contributions received from other sources (not participants or employers)	2010-12-31	$0
Other income received	2010-12-31	$3,086
Net income (gross income less expenses)	2010-12-31	$21,884
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$96,284
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$74,400
Assets. Value of participant loans	2010-12-31	$0
Total contributions received or receivable from employer(s)	2010-12-31	$6,443
Value of certain deemed distributions of participant loans	2010-12-31	$0
Value of corrective distributions	2010-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2010-12-31	$0
Minimum employer required contribution for this plan year	2010-12-31	$0
Amount contributed by the employer to the plan for this plan year	2010-12-31	$0
2009 : JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN 2009 401k financial data
Funding deficiency by the employer to the plan for this plan year	2009-12-31	$0
Minimum employer required contribution for this plan year	2009-12-31	$0
Amount contributed by the employer to the plan for this plan year	2009-12-31	$0

Form 5500 Responses for JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN

2013: JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	Yes
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
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
2012: JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN 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 – Trust	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: JOHN B. GOOLSBY, DMD, INC. 401(K) PLAN 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

Insurance Providers Used on plan

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )
Policy contract number	GA-809925
Policy instance	1
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )
Policy contract number	GA-809925
Policy instance	1
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )
Policy contract number	GA-809925
Policy instance	1
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )
Policy contract number	GA-809925
Policy instance	1

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Company Name:	JOHN B. GOOLSBY, DMD, INC.
Employer identification number (EIN):	550813168
NAIC Classification:	621210
NAIC Description:	Offices of Dentists