401k Plan data: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS plan

EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 401k Plan overview

Plan Name	EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS
Plan identification number	003

EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Money purchase (other than target benefit)
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 403(b)(1) arrangement - See Limited Pension Plan Reporting instructions for Code section 403(b)(1) arrangements for certain exempt organizations.
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

THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS has sponsored the creation of one or more 401k plans.

Company Name: THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS

Employer identification number (EIN): 620849787

NAIC Classification: 624100
NAIC Description: Individual and Family Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
003 2021-01-01 MARY LORD 2022-10-14
003 2020-01-01 MARY LORD 2021-07-30
003 2019-01-01 MARY LORD 2020-10-14
003 2018-01-01 MARY LORD 2019-10-14
003 2017-01-01 MARY LORD 2018-10-11
003 2016-01-01 MARY LORD
003 2015-01-01 MARY LORD
003 2014-01-01 MARY LORD
003 2013-01-01 MARY LORD
003 2012-01-01 MARY LORD
003 2011-01-01 MARY LORD
003 2010-01-01 MARY LORD
003 2009-01-01 MARY LORD

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
003	2021-01-01	MARY LORD	2022-10-14
003	2020-01-01	MARY LORD	2021-07-30
003	2019-01-01	MARY LORD	2020-10-14
003	2018-01-01	MARY LORD	2019-10-14
003	2017-01-01	MARY LORD	2018-10-11
003	2016-01-01	MARY LORD
003	2015-01-01	MARY LORD
003	2014-01-01	MARY LORD
003	2013-01-01	MARY LORD
003	2012-01-01	MARY LORD
003	2011-01-01	MARY LORD
003	2010-01-01	MARY LORD
003	2009-01-01	MARY LORD

Plan Statistics for EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS

401k plan membership statisitcs for EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS

Measure Date Value
2016: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2016 401k membership
Total participants, beginning-of-year 2016-01-01 5
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 5
Total of all active and inactive participants 2016-01-01 5
Total participants 2016-01-01 5
Number of participants with account balances 2016-01-01 5
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0
2015: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2015 401k membership
Total participants, beginning-of-year 2015-01-01 5
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 5
Total of all active and inactive participants 2015-01-01 5
Total participants 2015-01-01 5
Number of participants with account balances 2015-01-01 5
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 0
2014: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2014 401k membership
Total participants, beginning-of-year 2014-01-01 5
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 4
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 0
Total of all active and inactive participants 2014-01-01 4
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 4
Number of participants with account balances 2014-01-01 4
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2013 401k membership
Total participants, beginning-of-year 2013-01-01 6
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 5
Total of all active and inactive participants 2013-01-01 5
Total participants 2013-01-01 5
Number of participants with account balances 2013-01-01 5
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2012 401k membership
Total participants, beginning-of-year 2012-01-01 4
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 5
Number of other retired or separated participants entitled to future benefits 2012-01-01 1
Total of all active and inactive participants 2012-01-01 6
Total participants 2012-01-01 6
Number of participants with account balances 2012-01-01 6
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2011 401k membership
Total participants, beginning-of-year 2011-01-01 5
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 2
Number of other retired or separated participants entitled to future benefits 2011-01-01 2
Total of all active and inactive participants 2011-01-01 4
Total participants 2011-01-01 4
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 1
2010: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2010 401k membership
Total participants, beginning-of-year 2010-01-01 7
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 3
Number of other retired or separated participants entitled to future benefits 2010-01-01 2
Total of all active and inactive participants 2010-01-01 5
Total participants 2010-01-01 5
Number of participants with account balances 2010-01-01 5
2009: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2009 401k membership
Total participants, beginning-of-year 2009-01-01 3
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 2
Number of other retired or separated participants entitled to future benefits 2009-01-01 2
Total of all active and inactive participants 2009-01-01 4
Total participants 2009-01-01 4
Number of participants with account balances 2009-01-01 4
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2016: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2016 401k membership
Total participants, beginning-of-year	2016-01-01	5
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	5
Total of all active and inactive participants	2016-01-01	5
Total participants	2016-01-01	5
Number of participants with account balances	2016-01-01	5
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0
2015: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2015 401k membership
Total participants, beginning-of-year	2015-01-01	5
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	5
Total of all active and inactive participants	2015-01-01	5
Total participants	2015-01-01	5
Number of participants with account balances	2015-01-01	5
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	0
2014: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2014 401k membership
Total participants, beginning-of-year	2014-01-01	5
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	4
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	0
Total of all active and inactive participants	2014-01-01	4
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	4
Number of participants with account balances	2014-01-01	4
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2013 401k membership
Total participants, beginning-of-year	2013-01-01	6
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	5
Total of all active and inactive participants	2013-01-01	5
Total participants	2013-01-01	5
Number of participants with account balances	2013-01-01	5
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2012 401k membership
Total participants, beginning-of-year	2012-01-01	4
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	5
Number of other retired or separated participants entitled to future benefits	2012-01-01	1
Total of all active and inactive participants	2012-01-01	6
Total participants	2012-01-01	6
Number of participants with account balances	2012-01-01	6
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2011 401k membership
Total participants, beginning-of-year	2011-01-01	5
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	2
Number of other retired or separated participants entitled to future benefits	2011-01-01	2
Total of all active and inactive participants	2011-01-01	4
Total participants	2011-01-01	4
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	1
2010: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2010 401k membership
Total participants, beginning-of-year	2010-01-01	7
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	3
Number of other retired or separated participants entitled to future benefits	2010-01-01	2
Total of all active and inactive participants	2010-01-01	5
Total participants	2010-01-01	5
Number of participants with account balances	2010-01-01	5
2009: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2009 401k membership
Total participants, beginning-of-year	2009-01-01	3
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	2
Number of other retired or separated participants entitled to future benefits	2009-01-01	2
Total of all active and inactive participants	2009-01-01	4
Total participants	2009-01-01	4
Number of participants with account balances	2009-01-01	4
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS

Measure	Date	Value
2016 : EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2016 401k financial data
Total income from all sources	2016-12-31	$23,705
Expenses. Total of all expenses incurred	2016-12-31	$142
Total plan assets at end of year	2016-12-31	$87,049
Total plan assets at beginning of year	2016-12-31	$63,486
Value of fidelity bond covering the plan	2016-12-31	$10,000
Total contributions received or receivable from participants	2016-12-31	$5,528
Expenses. Other expenses not covered elsewhere	2016-12-31	$142
Other income received	2016-12-31	$7,744
Net income (gross income less expenses)	2016-12-31	$23,563
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$87,049
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$63,486
Total contributions received or receivable from employer(s)	2016-12-31	$10,433
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-12-31	$0
Minimum employer required contribution for this plan year	2016-12-31	$0
2015 : EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2015 401k financial data
Total income from all sources	2015-12-31	$12,701
Expenses. Total of all expenses incurred	2015-12-31	$106
Total plan assets at end of year	2015-12-31	$63,486
Total plan assets at beginning of year	2015-12-31	$50,891
Value of fidelity bond covering the plan	2015-12-31	$10,000
Total contributions received or receivable from participants	2015-12-31	$5,226
Other income received	2015-12-31	$-1,855
Net income (gross income less expenses)	2015-12-31	$12,595
Net plan assets at end of year (total assets less liabilities)	2015-12-31	$63,486
Net plan assets at beginning of year (total assets less liabilities)	2015-12-31	$50,891
Total contributions received or receivable from employer(s)	2015-12-31	$9,330
Expenses. Administrative service providers (salaries,fees and commissions)	2015-12-31	$106
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2015-12-31	$0
Minimum employer required contribution for this plan year	2015-12-31	$0
2014 : EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2014 401k financial data
Total income from all sources	2014-12-31	$10,150
Expenses. Total of all expenses incurred	2014-12-31	$4,370
Benefits paid (including direct rollovers)	2014-12-31	$4,370
Total plan assets at end of year	2014-12-31	$41,070
Total plan assets at beginning of year	2014-12-31	$35,290
Value of fidelity bond covering the plan	2014-12-31	$5,000
Other income received	2014-12-31	$1,314
Net income (gross income less expenses)	2014-12-31	$5,780
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$41,070
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$35,290
Total contributions received or receivable from employer(s)	2014-12-31	$8,836
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2014-12-31	$-8,836
Minimum employer required contribution for this plan year	2014-12-31	$0
Amount contributed by the employer to the plan for this plan year	2014-12-31	$8,836
2013 : EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2013 401k financial data
Total income from all sources	2013-12-31	$16,489
Expenses. Total of all expenses incurred	2013-12-31	$7,997
Benefits paid (including direct rollovers)	2013-12-31	$7,394
Total plan assets at end of year	2013-12-31	$35,290
Total plan assets at beginning of year	2013-12-31	$26,798
Value of fidelity bond covering the plan	2013-12-31	$5,000
Total contributions received or receivable from participants	2013-12-31	$0
Contributions received from other sources (not participants or employers)	2013-12-31	$0
Other income received	2013-12-31	$6,633
Noncash contributions received	2013-12-31	$0
Net income (gross income less expenses)	2013-12-31	$8,492
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$35,290
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$26,798
Total contributions received or receivable from employer(s)	2013-12-31	$9,856
Value of corrective distributions	2013-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2013-12-31	$603
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
Minimum employer required contribution for this plan year	2013-12-31	$0
2012 : EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2012 401k financial data
Total income from all sources	2012-12-31	$11,822
Expenses. Total of all expenses incurred	2012-12-31	$10,164
Benefits paid (including direct rollovers)	2012-12-31	$9,899
Total plan assets at end of year	2012-12-31	$26,798
Total plan assets at beginning of year	2012-12-31	$25,140
Value of fidelity bond covering the plan	2012-12-31	$5,000
Total contributions received or receivable from participants	2012-12-31	$0
Expenses. Other expenses not covered elsewhere	2012-12-31	$203
Other income received	2012-12-31	$2,648
Net income (gross income less expenses)	2012-12-31	$1,658
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$26,798
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$25,140
Total contributions received or receivable from employer(s)	2012-12-31	$9,174
Expenses. Administrative service providers (salaries,fees and commissions)	2012-12-31	$62
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	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 : EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2011 401k financial data
Total plan liabilities at beginning of year	2011-12-31	$0
Total income from all sources	2011-12-31	$132
Expenses. Total of all expenses incurred	2011-12-31	$561
Total plan assets at end of year	2011-12-31	$25,140
Total plan assets at beginning of year	2011-12-31	$25,569
Value of fidelity bond covering the plan	2011-12-31	$5,000
Other income received	2011-12-31	$132
Net income (gross income less expenses)	2011-12-31	$-429
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$25,140
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$25,569
Expenses. Administrative service providers (salaries,fees and commissions)	2011-12-31	$561
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2011-12-31	$0
2010 : EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 2010 401k financial data
Total plan liabilities at end of year	2010-12-31	$0
Total plan liabilities at beginning of year	2010-12-31	$0
Total income from all sources	2010-12-31	$1,844
Expenses. Total of all expenses incurred	2010-12-31	$359
Total plan assets at end of year	2010-12-31	$25,569
Total plan assets at beginning of year	2010-12-31	$24,084
Value of fidelity bond covering the plan	2010-12-31	$5,000
Total contributions received or receivable from participants	2010-12-31	$271
Other income received	2010-12-31	$1,573
Net income (gross income less expenses)	2010-12-31	$1,485
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$25,569
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$24,084
Expenses. Administrative service providers (salaries,fees and commissions)	2010-12-31	$359
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
2009 : EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 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 EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS

2016: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 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 – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 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 benefit arrangement – Insurance	Yes
2014: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 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 benefit arrangement – Insurance	Yes
2013: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 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 benefit arrangement – Insurance	Yes
2012: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 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 benefit arrangement – Insurance	Yes
2011: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 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 benefit arrangement – Insurance	Yes
2010: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 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 benefit arrangement – Insurance	Yes
2009: EMPLOYEE BENEFITS PLAN OF THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS 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 benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MUTUAL OF AMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88668 )

Policy contract number

051749-E

Policy instance

Insurance contract or identification number	051749-E
Number of Individuals Covered	4
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1
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	Yes
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	1
Additional information about fees paid to insurance broker	COMPENSATION
Insurance broker organization code?	3
Insurance broker name	NASHVILLE REGIONAL OFFICE

MUTUAL OF AMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88668 )

Policy contract number

051749-E

Policy instance

Insurance contract or identification number	051749-E
Number of Individuals Covered	4
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $18
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	Yes
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	18
Additional information about fees paid to insurance broker	COMPENSATION
Insurance broker organization code?	3
Insurance broker name	NASHVILLE REGIONAL OFFICE

MUTUAL OF AMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88668 )

Policy contract number

051749-E

Policy instance

Insurance contract or identification number	051749-E
Number of Individuals Covered	4
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $31
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

MUTUAL OF AMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88668 )

Policy contract number

051749-E

Policy instance

Insurance contract or identification number	051749-E
Number of Individuals Covered	5
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $20
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

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Company Name:	THE LEAH ROSE RESIDENCE FOR SENIOR CITIZENS
Employer identification number (EIN):	620849787
NAIC Classification:	624100
NAIC Description:	Individual and Family Services