401k Plan data: HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. plan

HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. 401k Plan overview

Plan Name	HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A.
Plan identification number	002

HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Offset plan - Plan benefits are subject to offset for retirement benefits provided in another plan or arrangement of the employer.
Profit-sharing
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

NEW TAMPA URGENT CARE has sponsored the creation of one or more 401k plans.

Company Name: NEW TAMPA URGENT CARE

Employer identification number (EIN): 710937927

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A.

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2013-01-01 LEE D. VOGT
002 2012-01-01 LEE D. VOGT
002 2011-01-01 LEE D. VOGT

Plan id#	Filing Submission Date	Name of Administrator
002	2013-01-01	LEE D. VOGT
002	2012-01-01	LEE D. VOGT
002	2011-01-01	LEE D. VOGT

Plan Statistics for HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A.

401k plan membership statisitcs for HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A.

Measure Date Value
2013: HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. 2013 401k membership
Total participants, beginning-of-year 2013-01-01 7
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 0
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 0
Total of all active and inactive participants 2013-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 0
Number of participants with account balances 2013-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. 2012 401k membership
Total participants, beginning-of-year 2012-01-01 7
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 7
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 0
Total of all active and inactive participants 2012-01-01 7
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 7
Number of participants with account balances 2012-01-01 5
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. 2011 401k membership
Total participants, beginning-of-year 2011-01-01 7
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 4
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 3
Total of all active and inactive participants 2011-01-01 7
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 7
Number of participants with account balances 2011-01-01 7
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 2

Measure	Date	Value
2013: HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. 2013 401k membership
Total participants, beginning-of-year	2013-01-01	7
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	0
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	0
Total of all active and inactive participants	2013-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	0
Number of participants with account balances	2013-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. 2012 401k membership
Total participants, beginning-of-year	2012-01-01	7
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	7
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	0
Total of all active and inactive participants	2012-01-01	7
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	7
Number of participants with account balances	2012-01-01	5
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. 2011 401k membership
Total participants, beginning-of-year	2011-01-01	7
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	4
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	3
Total of all active and inactive participants	2011-01-01	7
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	7
Number of participants with account balances	2011-01-01	7
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	2

Financial Data on HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A.

Measure	Date	Value
2013 : HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. 2013 401k financial data
Total income from all sources	2013-12-31	$153,437
Expenses. Total of all expenses incurred	2013-12-31	$890,614
Benefits paid (including direct rollovers)	2013-12-31	$887,722
Total plan assets at end of year	2013-12-31	$0
Total plan assets at beginning of year	2013-12-31	$737,177
Total contributions received or receivable from participants	2013-12-31	$12,562
Other income received	2013-12-31	$140,313
Net income (gross income less expenses)	2013-12-31	$-737,177
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$737,177
Total contributions received or receivable from employer(s)	2013-12-31	$562
Expenses. Administrative service providers (salaries,fees and commissions)	2013-12-31	$2,892
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
2012 : HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. 2012 401k financial data
Total income from all sources	2012-12-31	$145,617
Expenses. Total of all expenses incurred	2012-12-31	$5,045
Benefits paid (including direct rollovers)	2012-12-31	$4,520
Total plan assets at end of year	2012-12-31	$737,177
Total plan assets at beginning of year	2012-12-31	$596,605
Value of fidelity bond covering the plan	2012-12-31	$500,000
Total contributions received or receivable from participants	2012-12-31	$37,839
Other income received	2012-12-31	$90,939
Net income (gross income less expenses)	2012-12-31	$140,572
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$737,177
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$596,605
Total contributions received or receivable from employer(s)	2012-12-31	$16,839
Expenses. Administrative service providers (salaries,fees and commissions)	2012-12-31	$525
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
2011 : HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. 2011 401k financial data
Transfers to/from the plan	2011-12-31	$555,815
Total income from all sources	2011-12-31	$40,790
Expenses. Total of all expenses incurred	2011-12-31	$0
Total plan assets at end of year	2011-12-31	$596,605
Total plan assets at beginning of year	2011-12-31	$0
Value of fidelity bond covering the plan	2011-12-31	$500,000
Total contributions received or receivable from participants	2011-12-31	$2,030
Contributions received from other sources (not participants or employers)	2011-12-31	$0
Other income received	2011-12-31	$25,229
Noncash contributions received	2011-12-31	$0
Net income (gross income less expenses)	2011-12-31	$40,790
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$596,605
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$0
Total contributions received or receivable from employer(s)	2011-12-31	$13,531
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2011-12-31	$0

Form 5500 Responses for HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A.

2013: HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. 2013 form 5500 responses
2013-01-01	Type of plan entity	Mulitple employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	Yes
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	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 - Trust	Yes
2012: HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. 2012 form 5500 responses
2012-01-01	Type of plan entity	Mulitple 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 - Trust	Yes
2011: HARTFORD AFFILIATED EMPLOYERS RETIREMENT SAVINGS PLAN FBO MITCHELL FORMAN, M.D., P.A. 2011 form 5500 responses
2011-01-01	Type of plan entity	Mulitple 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 - Trust	Yes

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Company Name:	NEW TAMPA URGENT CARE
Employer identification number (EIN):	710937927
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)