401k Plan data: CLINTON COUNTY HOSPITAL INC 401(K) PLAN plan

CLINTON COUNTY HOSPITAL INC 401(K) PLAN 401k Plan overview

Plan Name	CLINTON COUNTY HOSPITAL INC 401(K) PLAN
Plan identification number	001

CLINTON COUNTY HOSPITAL INC 401(K) 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.
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

CLINTON COUNTY HOSPITAL INC has sponsored the creation of one or more 401k plans.

Company Name: CLINTON COUNTY HOSPITAL INC

Employer identification number (EIN): 616008014

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CLINTON COUNTY HOSPITAL INC 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2016-01-01 RONALD SOWELL
001 2015-01-01 RONALD SOWELL RONALD SOWELL 2016-10-12
001 2014-01-01 J D MULLINS J D MULLINS 2015-07-29
001 2013-01-01 J D MULLINS J D MULLINS 2014-07-10
001 2012-01-01 J.D. MULLINS J.D. MULLINS 2013-08-20
001 2011-01-01 J.D. MULLINS J.D. MULLINS 2012-09-19
001 2010-01-01 J.D. MULLINS J.D. MULLINS 2011-10-14
001 2009-09-01 J D MULLINS J D MULLINS 2010-07-30
001 2009-09-01 J.D. MULLINS J.D. MULLINS 2011-10-14
001 2009-09-01 J D MULLINS J D MULLINS 2010-07-30
001 2009-09-01 J.D. MULLINS J.D. MULLINS 2011-10-14

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
001	2016-01-01	RONALD SOWELL
001	2015-01-01	RONALD SOWELL	RONALD SOWELL	2016-10-12
001	2014-01-01	J D MULLINS	J D MULLINS	2015-07-29
001	2013-01-01	J D MULLINS	J D MULLINS	2014-07-10
001	2012-01-01	J.D. MULLINS	J.D. MULLINS	2013-08-20
001	2011-01-01	J.D. MULLINS	J.D. MULLINS	2012-09-19
001	2010-01-01	J.D. MULLINS	J.D. MULLINS	2011-10-14
001	2009-09-01	J D MULLINS	J D MULLINS	2010-07-30
001	2009-09-01	J.D. MULLINS	J.D. MULLINS	2011-10-14
001	2009-09-01	J D MULLINS	J D MULLINS	2010-07-30
001	2009-09-01	J.D. MULLINS	J.D. MULLINS	2011-10-14

Plan Statistics for CLINTON COUNTY HOSPITAL INC 401(K) PLAN

401k plan membership statisitcs for CLINTON COUNTY HOSPITAL INC 401(K) PLAN

Measure Date Value
2016: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 160
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
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 0
Total of all active and inactive participants 2016-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 0
Number of participants with account balances 2016-01-01 0
2015: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 161
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 135
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 12
Total of all active and inactive participants 2015-01-01 147
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 147
Number of participants with account balances 2015-01-01 135
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 0
2014: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 176
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 149
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 9
Total of all active and inactive participants 2014-01-01 158
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 2
Total participants 2014-01-01 160
Number of participants with account balances 2014-01-01 152
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 1
2013: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 192
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 162
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 11
Total of all active and inactive participants 2013-01-01 173
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 1
Total participants 2013-01-01 174
Number of participants with account balances 2013-01-01 165
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 3
2012: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 205
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 169
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 20
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 1
Total participants 2012-01-01 190
Number of participants with account balances 2012-01-01 178
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 5
2011: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 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 2011-01-01 181
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 15
Total of all active and inactive participants 2011-01-01 196
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 1
Total participants 2011-01-01 197
Number of participants with account balances 2011-01-01 185
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 5
2010: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 208
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 179
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 11
Total of all active and inactive participants 2010-01-01 190
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
Total participants 2010-01-01 190
Number of participants with account balances 2010-01-01 181
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 8
2009: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year 2009-09-01 206
Total number of active participants reported on line 7a of the Form 5500 2009-09-01 187
Number of retired or separated participants receiving benefits 2009-09-01 0
Number of other retired or separated participants entitled to future benefits 2009-09-01 12
Total of all active and inactive participants 2009-09-01 199
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-09-01 0
Total participants 2009-09-01 199
Number of participants with account balances 2009-09-01 187
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-09-01 2

Measure	Date	Value
2016: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	160
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
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	0
Total of all active and inactive participants	2016-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	0
Number of participants with account balances	2016-01-01	0
2015: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	161
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	135
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	12
Total of all active and inactive participants	2015-01-01	147
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	147
Number of participants with account balances	2015-01-01	135
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	0
2014: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	176
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	149
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	9
Total of all active and inactive participants	2014-01-01	158
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	2
Total participants	2014-01-01	160
Number of participants with account balances	2014-01-01	152
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	1
2013: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	192
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	162
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	11
Total of all active and inactive participants	2013-01-01	173
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	1
Total participants	2013-01-01	174
Number of participants with account balances	2013-01-01	165
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	3
2012: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	205
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	169
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	20
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	1
Total participants	2012-01-01	190
Number of participants with account balances	2012-01-01	178
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	5
2011: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 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	181
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	15
Total of all active and inactive participants	2011-01-01	196
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	1
Total participants	2011-01-01	197
Number of participants with account balances	2011-01-01	185
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	5
2010: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	208
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	179
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	11
Total of all active and inactive participants	2010-01-01	190
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	190
Number of participants with account balances	2010-01-01	181
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	8
2009: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year	2009-09-01	206
Total number of active participants reported on line 7a of the Form 5500	2009-09-01	187
Number of retired or separated participants receiving benefits	2009-09-01	0
Number of other retired or separated participants entitled to future benefits	2009-09-01	12
Total of all active and inactive participants	2009-09-01	199
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-09-01	0
Total participants	2009-09-01	199
Number of participants with account balances	2009-09-01	187
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-09-01	2

Financial Data on CLINTON COUNTY HOSPITAL INC 401(K) PLAN

Measure	Date	Value
2016 : CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2016 401k financial data
Total unrealized appreciation/depreciation of assets	2016-05-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-05-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-05-31	$0
Total income from all sources (including contributions)	2016-05-31	$67,971
Total loss/gain on sale of assets	2016-05-31	$0
Total of all expenses incurred	2016-05-31	$3,938,702
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-05-31	$3,927,392
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-05-31	$42,680
Value of total assets at end of year	2016-05-31	$0
Value of total assets at beginning of year	2016-05-31	$3,870,731
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-05-31	$11,310
Total interest from all sources	2016-05-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2016-05-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-05-31	Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan	2016-05-31	$0
Was this plan covered by a fidelity bond	2016-05-31	Yes
Value of fidelity bond cover	2016-05-31	$387,000
If this is an individual account plan, was there a blackout period	2016-05-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-05-31	$0
Were there any nonexempt tranactions with any party-in-interest	2016-05-31	No
Contributions received from participants	2016-05-31	$42,680
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-05-31	No
Value of net income/loss	2016-05-31	$-3,870,731
Value of net assets at end of year (total assets less liabilities)	2016-05-31	$0
Value of net assets at beginning of year (total assets less liabilities)	2016-05-31	$3,870,731
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-05-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-05-31	No
Were any leases to which the plan was party in default or uncollectible	2016-05-31	No
Investment advisory and management fees	2016-05-31	$283
Value of interest in pooled separate accounts at end of year	2016-05-31	$0
Value of interest in pooled separate accounts at beginning of year	2016-05-31	$3,869,604
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2016-05-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2016-05-31	$1,127
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2016-05-31	$1,127
Net investment gain/loss from pooled separate accounts	2016-05-31	$25,291
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-05-31	No
Was there a failure to transmit to the plan any participant contributions	2016-05-31	No
Has the plan failed to provide any benefit when due under the plan	2016-05-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-05-31	$3,927,392
Contract administrator fees	2016-05-31	$11,027
Did the plan have assets held for investment	2016-05-31	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	2016-05-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-05-31	Yes
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2016-05-31	Yes
Opinion of an independent qualified public accountant for this plan	2016-05-31	Disclaimer
Accountancy firm name	2016-05-31	BLUE & CO, LLC
Accountancy firm EIN	2016-05-31	351178661
2015 : CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2015 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2015-12-31	$-1,206
Total unrealized appreciation/depreciation of assets	2015-12-31	$-1,206
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	$64,916
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$230,716
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$224,979
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$181,143
Value of total assets at end of year	2015-12-31	$3,870,731
Value of total assets at beginning of year	2015-12-31	$4,036,531
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$5,737
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	$387,000
If this is an individual account plan, was there a blackout period	2015-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2015-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$178,639
Income. Received or receivable in cash from other sources (including rollovers)	2015-12-31	$2,504
Other income not declared elsewhere	2015-12-31	$1,363
Administrative expenses (other) incurred	2015-12-31	$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	2015-12-31	No
Value of net income/loss	2015-12-31	$-165,800
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$3,870,731
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$4,036,531
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
Investment advisory and management fees	2015-12-31	$4,292
Value of interest in pooled separate accounts at end of year	2015-12-31	$3,869,604
Value of interest in pooled separate accounts at beginning of year	2015-12-31	$3,939,118
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2015-12-31	$1,127
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2015-12-31	$3,413
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2015-12-31	$3,413
Net investment gain/loss from pooled separate accounts	2015-12-31	$-116,384
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	$0
Employer contributions (assets) at beginning of year	2015-12-31	$94,000
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$224,979
Contract administrator fees	2015-12-31	$1,445
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	BLUE & CO, LLC
Accountancy firm EIN	2015-12-31	351178661
2014 : CLINTON COUNTY HOSPITAL INC 401(K) PLAN 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	$401,364
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$231,189
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$225,537
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$280,817
Value of total assets at end of year	2014-12-31	$4,036,531
Value of total assets at beginning of year	2014-12-31	$3,866,356
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$5,652
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	$387,000
If this is an individual account plan, was there a blackout period	2014-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$185,559
Income. Received or receivable in cash from other sources (including rollovers)	2014-12-31	$15
Other income not declared elsewhere	2014-12-31	$199
Administrative expenses (other) incurred	2014-12-31	$4,052
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	$170,175
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$4,036,531
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$3,866,356
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	$3,939,118
Value of interest in pooled separate accounts at beginning of year	2014-12-31	$3,772,614
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2014-12-31	$3,413
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2014-12-31	$1,742
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2014-12-31	$1,742
Net investment gain/loss from pooled separate accounts	2014-12-31	$120,348
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	$95,243
Employer contributions (assets) at end of year	2014-12-31	$94,000
Employer contributions (assets) at beginning of year	2014-12-31	$92,000
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$225,537
Contract administrator fees	2014-12-31	$1,600
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	BLUE & CO, LLC
Accountancy firm EIN	2014-12-31	351178661
2013 : CLINTON COUNTY HOSPITAL INC 401(K) PLAN 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	$870,103
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$69,840
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$64,716
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$311,749
Value of total assets at end of year	2013-12-31	$3,866,356
Value of total assets at beginning of year	2013-12-31	$3,066,093
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$5,124
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	$375,000
If this is an individual account plan, was there a blackout period	2013-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$200,221
Income. Received or receivable in cash from other sources (including rollovers)	2013-12-31	$0
Administrative expenses (other) incurred	2013-12-31	$3,509
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
Income. Non cash contributions	2013-12-31	$17,956
Value of net income/loss	2013-12-31	$800,263
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$3,866,356
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$3,066,093
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	$3,772,614
Value of interest in pooled separate accounts at beginning of year	2013-12-31	$2,982,962
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2013-12-31	$1,742
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2013-12-31	$2,131
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2013-12-31	$2,131
Net investment gain/loss from pooled separate accounts	2013-12-31	$558,354
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	$93,572
Employer contributions (assets) at end of year	2013-12-31	$92,000
Employer contributions (assets) at beginning of year	2013-12-31	$81,000
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$64,716
Contract administrator fees	2013-12-31	$1,615
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	BLUE & CO, LLC
Accountancy firm EIN	2013-12-31	351178661
2012 : CLINTON COUNTY HOSPITAL INC 401(K) PLAN 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	$629,230
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$81,264
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$72,624
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$265,424
Value of total assets at end of year	2012-12-31	$3,066,093
Value of total assets at beginning of year	2012-12-31	$2,518,127
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$8,640
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
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$375,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$184,379
Income. Received or receivable in cash from other sources (including rollovers)	2012-12-31	$0
Administrative expenses (other) incurred	2012-12-31	$810
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	$547,966
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$3,066,093
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$2,518,127
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
Investment advisory and management fees	2012-12-31	$2,772
Value of interest in pooled separate accounts at end of year	2012-12-31	$2,982,962
Value of interest in pooled separate accounts at beginning of year	2012-12-31	$2,433,923
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2012-12-31	$2,131
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2012-12-31	$3,204
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2012-12-31	$3,204
Net investment gain/loss from pooled separate accounts	2012-12-31	$363,806
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	$81,045
Employer contributions (assets) at end of year	2012-12-31	$81,000
Employer contributions (assets) at beginning of year	2012-12-31	$81,000
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$72,624
Contract administrator fees	2012-12-31	$5,058
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	BLUE & CO, LLC
Accountancy firm EIN	2012-12-31	351178661
2011 : CLINTON COUNTY HOSPITAL INC 401(K) PLAN 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	$155,242
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$125,172
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$107,817
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$248,928
Value of total assets at end of year	2011-12-31	$2,518,127
Value of total assets at beginning of year	2011-12-31	$2,488,057
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$17,355
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	$375,000
If this is an individual account plan, was there a blackout period	2011-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2011-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$167,928
Income. Received or receivable in cash from other sources (including rollovers)	2011-12-31	$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	2011-12-31	No
Value of net income/loss	2011-12-31	$30,070
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$2,518,127
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$2,488,057
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
Investment advisory and management fees	2011-12-31	$17,355
Value of interest in pooled separate accounts at end of year	2011-12-31	$2,433,923
Value of interest in pooled separate accounts at beginning of year	2011-12-31	$2,397,424
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2011-12-31	$3,204
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2011-12-31	$1,586
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2011-12-31	$1,586
Net investment gain/loss from pooled separate accounts	2011-12-31	$-93,686
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	$81,000
Employer contributions (assets) at end of year	2011-12-31	$81,000
Employer contributions (assets) at beginning of year	2011-12-31	$89,047
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$107,817
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	BLUE & CO, LLC
Accountancy firm EIN	2011-12-31	351178661
2010 : CLINTON COUNTY HOSPITAL INC 401(K) PLAN 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	$566,906
Total loss/gain on sale of assets	2010-12-31	$0
Total of all expenses incurred	2010-12-31	$137,622
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$121,766
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$256,473
Value of total assets at end of year	2010-12-31	$2,488,057
Value of total assets at beginning of year	2010-12-31	$2,058,773
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$15,856
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	$375,000
If this is an individual account plan, was there a blackout period	2010-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$145,706
Participant contributions at beginning of year	2010-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2010-12-31	$22,701
Administrative expenses (other) incurred	2010-12-31	$2,178
Total non interest bearing cash at beginning of year	2010-12-31	$30,494
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	$429,284
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$2,488,057
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$2,058,773
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	$2,397,424
Value of interest in pooled separate accounts at beginning of year	2010-12-31	$2,028,279
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2010-12-31	$1,586
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	$310,433
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	Yes
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	$88,066
Employer contributions (assets) at end of year	2010-12-31	$89,047
Employer contributions (assets) at beginning of year	2010-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$121,766
Contract administrator fees	2010-12-31	$13,678
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	BLUE & CO., LLC
Accountancy firm EIN	2010-12-31	351178661
2009 : CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2009 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2009-12-31	$0

Form 5500 Responses for CLINTON COUNTY HOSPITAL INC 401(K) PLAN

2016: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 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	Yes
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
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: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 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: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 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: CLINTON COUNTY HOSPITAL 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	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: CLINTON COUNTY HOSPITAL 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
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: CLINTON COUNTY HOSPITAL 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
2011-01-01	Plan benefit arrangement - Trust	Yes
2010: CLINTON COUNTY HOSPITAL 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
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: CLINTON COUNTY HOSPITAL INC 401(K) PLAN 2009 form 5500 responses
2009-09-01	Type of plan entity	Single employer plan
2009-09-01	Submission has been amended	No
2009-09-01	This submission is the final filing	No
2009-09-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2009-09-01	Plan is a collectively bargained plan	No
2009-09-01	Plan funding arrangement – Insurance	Yes
2009-09-01	Plan funding arrangement – Trust	Yes
2009-09-01	Plan benefit arrangement – Insurance	Yes
2009-09-01	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

93788

Policy instance

Insurance contract or identification number	93788
Number of Individuals Covered	0
Insurance policy start date	2016-01-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $6,767
Total amount of fees paid to insurance company	USD $618
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 $6,767
Insurance broker organization code?	4
Amount paid for insurance broker fees	618
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	EMPLOYEE BENEFIT SERVICES INC

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

Policy contract number

93788

Policy instance

Insurance contract or identification number	93788
Number of Individuals Covered	145
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $17,525
Total amount of fees paid to insurance company	USD $3,446
Commission paid to Insurance Broker	USD $17,525
Amount paid for insurance broker fees	0
Insurance broker organization code?	4
Additional information about fees paid to insurance broker	TPA FEES PAID AND COMPENSATION
Insurance broker name	EMPLOYEE BENEFIT SERVICES INC

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

Policy contract number

93788

Policy instance

Insurance contract or identification number	93788
Number of Individuals Covered	156
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $17,297
Total amount of fees paid to insurance company	USD $3,571
Commission paid to Insurance Broker	USD $17,297
Amount paid for insurance broker fees	0
Insurance broker organization code?	4
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	EMPLOYEE BENEFIT SERVICES INC

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

Policy contract number

93788

Policy instance

Insurance contract or identification number	93788
Number of Individuals Covered	166
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $14,746
Total amount of fees paid to insurance company	USD $3,295
Commission paid to Insurance Broker	USD $14,746
Amount paid for insurance broker fees	0
Insurance broker organization code?	4
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	EMPLOYEE BENEFIT SERVICES INC

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

Policy contract number

93788

Policy instance

Insurance contract or identification number	93788
Number of Individuals Covered	182
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $12,712
Total amount of fees paid to insurance company	USD $2,183
Commission paid to Insurance Broker	USD $12,712
Amount paid for insurance broker fees	0
Insurance broker organization code?	4
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	EMPLOYEE BENEFIT SERVICES INC

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

Policy contract number

93788

Policy instance

Insurance contract or identification number	93788
Number of Individuals Covered	185
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $12,537
Total amount of fees paid to insurance company	USD $2,214

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

Policy contract number

93788

Policy instance

Insurance contract or identification number	93788
Number of Individuals Covered	166
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $9,975
Total amount of fees paid to insurance company	USD $4,873
Commission paid to Insurance Broker	USD $9,975
Amount paid for insurance broker fees	0
Insurance broker organization code?	4
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	EMPLOYEE BENEFIT SERVICES, INC

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Company Name:	CLINTON COUNTY HOSPITAL INC
Employer identification number (EIN):	616008014
NAIC Classification:	622000
NAIC Description:	Hospitals