401k Plan data: TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME plan

TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME 401k Plan overview

Plan Name	TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME
Plan identification number	002

TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME Benefits

401k Plan Type	Defined Contribution Pension
Plan Features/Benefits	Code section 403(b)(1) arrangement - See Limited Pension Plan Reporting instructions for Code section 403(b)(1) arrangements for certain exempt organizations.

401k Sponsoring company profile

MOUNT CARMEL REHABILITATION AND NURSING CENTER has sponsored the creation of one or more 401k plans.

Company Name: MOUNT CARMEL REHABILITATION AND NURSING CENTER

Employer identification number (EIN): 020276834

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2013-01-01 JOE BOHUNICKY 2014-03-08
002 2012-01-01 JOE BOHUNICKY 2013-10-14
002 2011-01-01 JOE BOHUNICKY 2013-05-28
002 2010-01-01 JOE BOHUNICKY
002 2009-01-01 JOE BOHUNICKY
002 2009-01-01 JOSEPH BOHUNICKY

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
002	2013-01-01	JOE BOHUNICKY	2014-03-08
002	2012-01-01	JOE BOHUNICKY	2013-10-14
002	2011-01-01	JOE BOHUNICKY	2013-05-28
002	2010-01-01	JOE BOHUNICKY
002	2009-01-01	JOE BOHUNICKY
002	2009-01-01	JOSEPH BOHUNICKY

Plan Statistics for TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME

401k plan membership statisitcs for TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME

Measure Date Value
2010: TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME 2010 401k membership
Total participants, beginning-of-year 2010-01-01 15
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 9
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 4
Total of all active and inactive participants 2010-01-01 13
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
Total participants 2010-01-01 13
Number of participants with account balances 2010-01-01 13
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 0
2009: TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME 2009 401k membership
Total participants, beginning-of-year 2009-01-01 17
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 9
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 5
Total of all active and inactive participants 2009-01-01 14
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 1
Total participants 2009-01-01 15
Number of participants with account balances 2009-01-01 15
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2010: TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME 2010 401k membership
Total participants, beginning-of-year	2010-01-01	15
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	9
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	4
Total of all active and inactive participants	2010-01-01	13
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	13
Number of participants with account balances	2010-01-01	13
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	0
2009: TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME 2009 401k membership
Total participants, beginning-of-year	2009-01-01	17
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	9
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	5
Total of all active and inactive participants	2009-01-01	14
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	1
Total participants	2009-01-01	15
Number of participants with account balances	2009-01-01	15
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME

Measure	Date	Value
2011 : TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME 2011 401k financial data
Total income from all sources (including contributions)	2011-12-31	$2,048
Total of all expenses incurred	2011-12-31	$5,004
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$4,920
Value of total assets at end of year	2011-12-31	$76,401
Value of total assets at beginning of year	2011-12-31	$79,358
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$84
Total interest from all sources	2011-12-31	$2,048
Was this plan covered by a fidelity bond	2011-12-31	Yes
Value of fidelity bond cover	2011-12-31	$2,000,000
If this is an individual account plan, was there a blackout period	2011-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
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	$-2,956
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$76,401
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$79,358
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
Value of interest in pooled separate accounts at end of year	2011-12-31	$4,576
Value of interest in pooled separate accounts at beginning of year	2011-12-31	$4,672
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2011-12-31	$2,048
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-12-31	$71,825
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2011-12-31	$74,686
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
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$4,920
Contract administrator fees	2011-12-31	$84
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	2011-12-31	No
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
2010 : TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME 2010 401k financial data
Total income from all sources (including contributions)	2010-12-31	$3,250
Total of all expenses incurred	2010-12-31	$5,199
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$5,081
Value of total assets at end of year	2010-12-31	$79,358
Value of total assets at beginning of year	2010-12-31	$81,306
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$118
Total interest from all sources	2010-12-31	$3,250
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$2,000,000
If this is an individual account plan, was there a blackout period	2010-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
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	$-1,949
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$79,358
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$81,306
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	$4,672
Value of interest in pooled separate accounts at beginning of year	2010-12-31	$8,686
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2010-12-31	$3,250
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$74,686
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$72,620
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	No
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$5,081
Contract administrator fees	2010-12-31	$118
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	2010-12-31	No
Did the plan have assets held for investment	2010-12-31	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	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

Form 5500 Responses for TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME

2010: TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	First time form 5500 has been submitted	Yes
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: TAX DEFERRED ANNUITY PLAN OF MOUNT CARMEL NURSING HOME 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
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

007369F

Policy instance

Insurance contract or identification number	007369F
Number of Individuals Covered	13
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Contracts With Unallocated Funds Deposit Administration	1

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Company Name:	MOUNT CARMEL REHABILITATION AND NURSING CENTER
Employer identification number (EIN):	020276834
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities