401k Plan data: EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE plan

EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE 401k Plan overview

Plan Name	EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE
Plan identification number	510

EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision)

401k Sponsoring company profile

MISKELLY FURNITURE WAREHOUSE, INC. has sponsored the creation of one or more 401k plans.

Company Name: MISKELLY FURNITURE WAREHOUSE, INC.

Employer identification number (EIN): 640616673

NAIC Classification: 442110
NAIC Description: Furniture Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
510 2017-09-01
510 2017-09-01
510 2016-09-01 OSCAR MISKELLY OSCAR MISKELLY 2018-06-15
510 2015-09-01 OSCAR MISKELLY 2017-01-18 OSCAR MISKELLY 2017-01-18
510 2014-09-01 OSCAR MISKELLY 2016-01-13 OSCAR MISKELLY 2016-01-13
510 2013-09-01 OSCAR MISKELLY 2015-01-06 OSCAR MISKELLY 2015-01-06
510 2012-09-01 OSCAR MISKELLY 2014-01-10 OSCAR MISKELLY 2014-01-10
510 2011-09-01 OSCAR MISKELLY 2012-12-12 OSCAR MISKELLY 2012-12-12
510 2010-09-01 OSCAR MISKELLY 2011-12-30 OSCAR MISKELLY 2011-12-30

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
510	2017-09-01
510	2017-09-01
510	2016-09-01	OSCAR MISKELLY		OSCAR MISKELLY	2018-06-15
510	2015-09-01	OSCAR MISKELLY	2017-01-18	OSCAR MISKELLY	2017-01-18
510	2014-09-01	OSCAR MISKELLY	2016-01-13	OSCAR MISKELLY	2016-01-13
510	2013-09-01	OSCAR MISKELLY	2015-01-06	OSCAR MISKELLY	2015-01-06
510	2012-09-01	OSCAR MISKELLY	2014-01-10	OSCAR MISKELLY	2014-01-10
510	2011-09-01	OSCAR MISKELLY	2012-12-12	OSCAR MISKELLY	2012-12-12
510	2010-09-01	OSCAR MISKELLY	2011-12-30	OSCAR MISKELLY	2011-12-30

Plan Statistics for EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE

401k plan membership statisitcs for EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE

Measure Date Value
2017: EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE 2017 401k membership
Total participants, beginning-of-year 2017-09-01 124
Total number of active participants reported on line 7a of the Form 5500 2017-09-01 131
Number of retired or separated participants receiving benefits 2017-09-01 0
Number of other retired or separated participants entitled to future benefits 2017-09-01 0
Total of all active and inactive participants 2017-09-01 131
2016: EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE 2016 401k membership
Total participants, beginning-of-year 2016-09-01 128
Total number of active participants reported on line 7a of the Form 5500 2016-09-01 124
Total of all active and inactive participants 2016-09-01 124

Measure	Date	Value
2017: EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE 2017 401k membership
Total participants, beginning-of-year	2017-09-01	124
Total number of active participants reported on line 7a of the Form 5500	2017-09-01	131
Number of retired or separated participants receiving benefits	2017-09-01	0
Number of other retired or separated participants entitled to future benefits	2017-09-01	0
Total of all active and inactive participants	2017-09-01	131
2016: EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE 2016 401k membership
Total participants, beginning-of-year	2016-09-01	128
Total number of active participants reported on line 7a of the Form 5500	2016-09-01	124
Total of all active and inactive participants	2016-09-01	124

Financial Data on EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE

Measure	Date	Value
2018 : EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-08-31	$0
Total transfer of assets from this plan	2018-08-31	$47,615
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-08-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-08-31	$0
Total income from all sources (including contributions)	2018-08-31	$1,064,394
Total loss/gain on sale of assets	2018-08-31	$0
Total of all expenses incurred	2018-08-31	$1,017,107
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-08-31	$964,053
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-08-31	$1,064,394
Value of total assets at end of year	2018-08-31	$47,615
Value of total assets at beginning of year	2018-08-31	$328
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-08-31	$53,054
Total interest from all sources	2018-08-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2018-08-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-08-31	No
Was this plan covered by a fidelity bond	2018-08-31	Yes
Value of fidelity bond cover	2018-08-31	$500,000
If this is an individual account plan, was there a blackout period	2018-08-31	No
Were there any nonexempt tranactions with any party-in-interest	2018-08-31	No
Contributions received from participants	2018-08-31	$523,694
Total non interest bearing cash at end of year	2018-08-31	$47,615
Total non interest bearing cash at beginning of year	2018-08-31	$328
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-08-31	No
Value of net income/loss	2018-08-31	$47,287
Value of net assets at end of year (total assets less liabilities)	2018-08-31	$47,615
Value of net assets at beginning of year (total assets less liabilities)	2018-08-31	$328
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-08-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-08-31	No
Were any leases to which the plan was party in default or uncollectible	2018-08-31	No
Expenses. Payments to insurance carriers foe the provision of benefits	2018-08-31	$964,053
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-08-31	No
Was there a failure to transmit to the plan any participant contributions	2018-08-31	No
Has the plan failed to provide any benefit when due under the plan	2018-08-31	No
Contributions received in cash from employer	2018-08-31	$540,700
Contract administrator fees	2018-08-31	$53,054
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2018-08-31	No
Did the plan have assets held for investment	2018-08-31	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	2018-08-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-08-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-08-31	No
Opinion of an independent qualified public accountant for this plan	2018-08-31	Unqualified
Accountancy firm name	2018-08-31	HARPER RAINES KNIGHT & COMPANY
Accountancy firm EIN	2018-08-31	640809101
2017 : EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE 2017 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-08-31	$0
Total income from all sources (including contributions)	2017-08-31	$1,014,564
Total of all expenses incurred	2017-08-31	$1,014,874
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-08-31	$978,934
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-08-31	$1,014,564
Value of total assets at end of year	2017-08-31	$328
Value of total assets at beginning of year	2017-08-31	$638
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-08-31	$35,940
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-08-31	No
Was this plan covered by a fidelity bond	2017-08-31	No
Were there any nonexempt tranactions with any party-in-interest	2017-08-31	No
Contributions received from participants	2017-08-31	$525,438
Other income not declared elsewhere	2017-08-31	$0
Administrative expenses (other) incurred	2017-08-31	$0
Total non interest bearing cash at end of year	2017-08-31	$328
Total non interest bearing cash at beginning of year	2017-08-31	$638
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-08-31	No
Value of net income/loss	2017-08-31	$-310
Value of net assets at end of year (total assets less liabilities)	2017-08-31	$328
Value of net assets at beginning of year (total assets less liabilities)	2017-08-31	$638
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-08-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-08-31	No
Were any leases to which the plan was party in default or uncollectible	2017-08-31	No
Expenses. Payments to insurance carriers foe the provision of benefits	2017-08-31	$978,934
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-08-31	No
Was there a failure to transmit to the plan any participant contributions	2017-08-31	No
Has the plan failed to provide any benefit when due under the plan	2017-08-31	No
Contributions received in cash from employer	2017-08-31	$489,126
Employer contributions (assets) at beginning of year	2017-08-31	$0
Contract administrator fees	2017-08-31	$35,940
Liabilities. Value of benefit claims payable at end of year	2017-08-31	$0
Did the plan have assets held for investment	2017-08-31	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	2017-08-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-08-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-08-31	No
Opinion of an independent qualified public accountant for this plan	2017-08-31	Unqualified
Accountancy firm name	2017-08-31	HARPER RAINES KNIGHT & COMPANY
Accountancy firm EIN	2017-08-31	640809101

Form 5500 Responses for EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE

2017: EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE 2017 form 5500 responses
2017-09-01	Type of plan entity	Single employer plan
2017-09-01	Submission has been amended	No
2017-09-01	This submission is the final filing	No
2017-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-09-01	Plan is a collectively bargained plan	No
2017-09-01	Plan funding arrangement – Insurance	Yes
2017-09-01	Plan funding arrangement – Trust	Yes
2017-09-01	Plan benefit arrangement – Insurance	Yes
2017-09-01	Plan benefit arrangement - Trust	Yes
2016: EMPLOYEE MEDICAL BENEFIT PLAN FOR MISKELLY FURNITURE 2016 form 5500 responses
2016-09-01	Type of plan entity	Single employer plan
2016-09-01	Submission has been amended	No
2016-09-01	This submission is the final filing	No
2016-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-09-01	Plan is a collectively bargained plan	No
2016-09-01	Plan funding arrangement – Insurance	Yes
2016-09-01	Plan funding arrangement – Trust	Yes
2016-09-01	Plan benefit arrangement – Insurance	Yes
2016-09-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

GREENWICH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22322 )

Policy contract number

SXTG1002-17

Policy instance

Insurance contract or identification number	SXTG1002-17
Number of Individuals Covered	131
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
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
Welfare Benefit Premiums Paid to Carrier	USD $141,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

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Company Name:	MISKELLY FURNITURE WAREHOUSE, INC.
Employer identification number (EIN):	640616673
NAIC Classification:	442110
NAIC Description:	Furniture Stores