401k Plan data: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST plan

CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 401k Plan overview

Plan Name	CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST
Plan identification number	001

CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Age/Service Weighted or new comparability or similar plan - Age/Service Weighted Plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the theshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of section 401(l).
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.
Participant-directed brokerage accounts provided as an investment option under the plan.
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.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

CITIZENS STATE BANK has sponsored the creation of one or more 401k plans.

Company Name: CITIZENS STATE BANK

Employer identification number (EIN): 590828474

NAIC Classification: 812990
NAIC Description: All Other Personal Services

Additional information about CITIZENS STATE BANK

Jurisdiction of Incorporation: Florida Department of State Division of Corporations

Incorporation Date: 1958-01-15

Company Identification Number: 209089

Legal Registered Office Address: 13840 W. Newberry Rd.

Newberry

32669

More information about CITIZENS STATE BANK

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2019-01-01 GILBERT A. LEVY 2020-02-10
001 2018-01-01 GILBERT A. LEVY 2019-10-01
001 2017-01-01 GILBERT A. LEVY
001 2016-01-01 NICOLLE PACK
001 2015-01-01 MICHAEL T. FARRELL
001 2013-01-01 JENNIFER HORN 2015-11-11
001 2012-01-01 ROGER BROOKS 2013-10-09
001 2011-01-01 ROGER BROOKS 2013-02-26
001 2010-01-01 ROGER BROOKS 2011-10-13

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
001	2019-01-01	GILBERT A. LEVY	2020-02-10
001	2018-01-01	GILBERT A. LEVY	2019-10-01
001	2017-01-01	GILBERT A. LEVY
001	2016-01-01	NICOLLE PACK
001	2015-01-01	MICHAEL T. FARRELL
001	2013-01-01	JENNIFER HORN	2015-11-11
001	2012-01-01	ROGER BROOKS	2013-10-09
001	2011-01-01	ROGER BROOKS	2013-02-26
001	2010-01-01	ROGER BROOKS	2011-10-13

Plan Statistics for CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST

401k plan membership statisitcs for CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST

Measure Date Value
2019: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2019 401k membership
Total participants, beginning-of-year 2019-01-01 59
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 0
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 0
Number of participants with account balances 2019-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 0
2018: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2018 401k membership
Total participants, beginning-of-year 2018-01-01 48
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 59
Number of retired or separated participants receiving benefits 2018-01-01 1
Number of other retired or separated participants entitled to future benefits 2018-01-01 15
Total of all active and inactive participants 2018-01-01 75
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 75
Number of participants with account balances 2018-01-01 58
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 2
2017: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2017 401k membership
Total participants, beginning-of-year 2017-01-01 72
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 61
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 13
Total of all active and inactive participants 2017-01-01 74
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 74
Number of participants with account balances 2017-01-01 58
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 8
2016: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2016 401k membership
Total participants, beginning-of-year 2016-01-01 70
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 58
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 14
Total of all active and inactive participants 2016-01-01 72
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 72
Number of participants with account balances 2016-01-01 63
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 7
2015: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2015 401k membership
Total participants, beginning-of-year 2015-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 63
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 6
Total of all active and inactive participants 2015-01-01 69
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 69
Number of participants with account balances 2015-01-01 62
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 4

Measure	Date	Value
2019: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2019 401k membership
Total participants, beginning-of-year	2019-01-01	59
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	0
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	0
Number of participants with account balances	2019-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	0
2018: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2018 401k membership
Total participants, beginning-of-year	2018-01-01	48
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	59
Number of retired or separated participants receiving benefits	2018-01-01	1
Number of other retired or separated participants entitled to future benefits	2018-01-01	15
Total of all active and inactive participants	2018-01-01	75
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	75
Number of participants with account balances	2018-01-01	58
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	2
2017: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2017 401k membership
Total participants, beginning-of-year	2017-01-01	72
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	61
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	13
Total of all active and inactive participants	2017-01-01	74
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	74
Number of participants with account balances	2017-01-01	58
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	8
2016: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2016 401k membership
Total participants, beginning-of-year	2016-01-01	70
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	58
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	14
Total of all active and inactive participants	2016-01-01	72
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	72
Number of participants with account balances	2016-01-01	63
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	7
2015: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2015 401k membership
Total participants, beginning-of-year	2015-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	63
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	6
Total of all active and inactive participants	2015-01-01	69
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	69
Number of participants with account balances	2015-01-01	62
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	4

Financial Data on CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST

Measure	Date	Value
2019 : CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2019 401k financial data
Total plan liabilities at end of year	2019-09-30	$0
Total plan liabilities at beginning of year	2019-09-30	$0
Total income from all sources	2019-09-30	$322,525
Expenses. Total of all expenses incurred	2019-09-30	$1,347,999
Benefits paid (including direct rollovers)	2019-09-30	$1,334,612
Total plan assets at end of year	2019-09-30	$0
Total plan assets at beginning of year	2019-09-30	$1,025,474
Value of fidelity bond covering the plan	2019-09-30	$500,000
Total contributions received or receivable from participants	2019-09-30	$140,815
Expenses. Other expenses not covered elsewhere	2019-09-30	$9,912
Other income received	2019-09-30	$116,450
Net income (gross income less expenses)	2019-09-30	$-1,025,474
Net plan assets at end of year (total assets less liabilities)	2019-09-30	$0
Net plan assets at beginning of year (total assets less liabilities)	2019-09-30	$1,025,474
Total contributions received or receivable from employer(s)	2019-09-30	$65,260
Expenses. Administrative service providers (salaries,fees and commissions)	2019-09-30	$3,475
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-09-30	$0
2018 : CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2018 401k financial data
Total plan liabilities at end of year	2018-12-31	$0
Total plan liabilities at beginning of year	2018-12-31	$0
Total income from all sources	2018-12-31	$226,768
Expenses. Total of all expenses incurred	2018-12-31	$651,083
Benefits paid (including direct rollovers)	2018-12-31	$646,194
Total plan assets at end of year	2018-12-31	$1,025,474
Total plan assets at beginning of year	2018-12-31	$1,449,789
Value of fidelity bond covering the plan	2018-12-31	$500,000
Total contributions received or receivable from participants	2018-12-31	$183,156
Expenses. Other expenses not covered elsewhere	2018-12-31	$3,211
Contributions received from other sources (not participants or employers)	2018-12-31	$7,100
Other income received	2018-12-31	$-65,902
Net income (gross income less expenses)	2018-12-31	$-424,315
Net plan assets at end of year (total assets less liabilities)	2018-12-31	$1,025,474
Net plan assets at beginning of year (total assets less liabilities)	2018-12-31	$1,449,789
Assets. Value of participant loans	2018-12-31	$57,739
Total contributions received or receivable from employer(s)	2018-12-31	$102,414
Value of certain deemed distributions of participant loans	2018-12-31	$1,678
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-12-31	$0
2017 : CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2017 401k financial data
Transfers to/from the plan	2017-12-31	$0
Total plan liabilities at end of year	2017-12-31	$0
Total plan liabilities at beginning of year	2017-12-31	$0
Total income from all sources	2017-12-31	$439,301
Expenses. Total of all expenses incurred	2017-12-31	$385,272
Benefits paid (including direct rollovers)	2017-12-31	$377,502
Total plan assets at end of year	2017-12-31	$1,449,789
Total plan assets at beginning of year	2017-12-31	$1,395,760
Value of fidelity bond covering the plan	2017-12-31	$0
Total contributions received or receivable from participants	2017-12-31	$158,050
Expenses. Other expenses not covered elsewhere	2017-12-31	$0
Contributions received from other sources (not participants or employers)	2017-12-31	$0
Other income received	2017-12-31	$200,417
Net income (gross income less expenses)	2017-12-31	$54,029
Net plan assets at end of year (total assets less liabilities)	2017-12-31	$1,449,789
Net plan assets at beginning of year (total assets less liabilities)	2017-12-31	$1,395,760
Assets. Value of participant loans	2017-12-31	$49,255
Total contributions received or receivable from employer(s)	2017-12-31	$80,834
Value of certain deemed distributions of participant loans	2017-12-31	$0
Value of corrective distributions	2017-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2017-12-31	$7,770
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2017-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2017-12-31	$0
Minimum employer required contribution for this plan year	2017-12-31	$0
Amount contributed by the employer to the plan for this plan year	2017-12-31	$0
2016 : CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2016 401k financial data
Transfers to/from the plan	2016-12-31	$0
Total plan liabilities at end of year	2016-12-31	$0
Total plan liabilities at beginning of year	2016-12-31	$0
Total income from all sources	2016-12-31	$340,948
Expenses. Total of all expenses incurred	2016-12-31	$139,078
Benefits paid (including direct rollovers)	2016-12-31	$138,083
Total plan assets at end of year	2016-12-31	$1,395,760
Total plan assets at beginning of year	2016-12-31	$1,193,890
Value of fidelity bond covering the plan	2016-12-31	$0
Total contributions received or receivable from participants	2016-12-31	$170,235
Expenses. Other expenses not covered elsewhere	2016-12-31	$0
Contributions received from other sources (not participants or employers)	2016-12-31	$814
Other income received	2016-12-31	$67,215
Net income (gross income less expenses)	2016-12-31	$201,870
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$1,395,760
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$1,193,890
Assets. Value of participant loans	2016-12-31	$52,206
Total contributions received or receivable from employer(s)	2016-12-31	$102,684
Value of certain deemed distributions of participant loans	2016-12-31	$0
Value of corrective distributions	2016-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2016-12-31	$995
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2016-12-31	$0
Minimum employer required contribution for this plan year	2016-12-31	$0
Amount contributed by the employer to the plan for this plan year	2016-12-31	$0
2015 : CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2015 401k financial data
Transfers to/from the plan	2015-12-31	$0
Total plan liabilities at end of year	2015-12-31	$0
Total plan liabilities at beginning of year	2015-12-31	$0
Total income from all sources	2015-12-31	$1,208,730
Expenses. Total of all expenses incurred	2015-12-31	$14,840
Benefits paid (including direct rollovers)	2015-12-31	$14,840
Total plan assets at end of year	2015-12-31	$1,193,890
Total plan assets at beginning of year	2015-12-31	$0
Value of fidelity bond covering the plan	2015-12-31	$0
Total contributions received or receivable from participants	2015-12-31	$124,443
Expenses. Other expenses not covered elsewhere	2015-12-31	$0
Contributions received from other sources (not participants or employers)	2015-12-31	$0
Other income received	2015-12-31	$1,007,163
Net income (gross income less expenses)	2015-12-31	$1,193,890
Net plan assets at end of year (total assets less liabilities)	2015-12-31	$1,193,890
Net plan assets at beginning of year (total assets less liabilities)	2015-12-31	$0
Assets. Value of participant loans	2015-12-31	$62,418
Total contributions received or receivable from employer(s)	2015-12-31	$77,124
Value of certain deemed distributions of participant loans	2015-12-31	$0
Value of corrective distributions	2015-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2015-12-31	$0

Form 5500 Responses for CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST

2019: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	Yes
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 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	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 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 – Trust	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: CITIZENS STATE BANK 401(K) PROFIT SHARING PLAN & TRUST 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 – Trust	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

GA-842674

Policy instance

Insurance contract or identification number	GA-842674
Number of Individuals Covered	0
Insurance policy start date	2019-01-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $2,803
Total amount of fees paid to insurance company	USD $122
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,803
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	BROKERAGE
Insurance broker organization code?	4

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

GA-842674

Policy instance

Insurance contract or identification number	GA-842674
Number of Individuals Covered	58
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,848
Total amount of fees paid to insurance company	USD $4,297
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	4000
Additional information about fees paid to insurance broker	ADMINISTRATIVE
Insurance broker organization code?	5

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Company Name:	CITIZENS STATE BANK
Employer identification number (EIN):	590828474
NAIC Classification:	812990
NAIC Description:	All Other Personal Services

Jurisdiction of Incorporation:	Florida Department of State Division of Corporations
Incorporation Date:	1958-01-15
Company Identification Number:	209089
Legal Registered Office Address:	13840 W. Newberry Rd. Newberry 32669