401k Plan data: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN plan

BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 401k Plan overview

Plan Name	BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN
Plan identification number	002

BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Age/Service Weighted or new comparability or similar plan - Age/Service Weighted Plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the theshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of section 401(l).
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.
Code section 403(b)(7) accounts - See Limited Pension Plan Reporting instructions for Code section 403(b)(7) custodial accounts for regulated investment company stock for certain exempt organizations.
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.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

BERKSHIRE RETIREMENT HOME, INC. has sponsored the creation of one or more 401k plans.

Company Name: BERKSHIRE RETIREMENT HOME, INC.

Employer identification number (EIN): 042103875

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2022-06-01
002 2021-06-01
002 2020-06-01
002 2019-06-01
002 2019-06-01
002 2018-06-01
002 2018-06-01
002 2017-06-01 EDWARD FORFA
002 2017-06-01
002 2016-06-01 EDWARD FORFA 2017-12-29
002 2015-06-01 EDWARD FORFA 2017-04-04
002 2015-06-01 EDWARD FORFA 2017-03-23
002 2014-06-01 EDWARD FORFA 2015-12-30
002 2013-06-01 EDWARD FORFA 2015-03-16
002 2012-06-01 EDWARD FORFA 2014-03-17
002 2011-06-01 EDWARD FORFA 2013-03-15
002 2010-06-01 EDWARD FORFA 2012-01-17
002 2009-06-01 EDWARD FORFA
002 2009-06-01 EDWARD FORFA

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
002	2022-06-01
002	2021-06-01
002	2020-06-01
002	2019-06-01
002	2019-06-01
002	2018-06-01
002	2018-06-01
002	2017-06-01	EDWARD FORFA
002	2017-06-01
002	2016-06-01	EDWARD FORFA	2017-12-29
002	2015-06-01	EDWARD FORFA	2017-04-04
002	2015-06-01	EDWARD FORFA	2017-03-23
002	2014-06-01	EDWARD FORFA	2015-12-30
002	2013-06-01	EDWARD FORFA	2015-03-16
002	2012-06-01	EDWARD FORFA	2014-03-17
002	2011-06-01	EDWARD FORFA	2013-03-15
002	2010-06-01	EDWARD FORFA	2012-01-17
002	2009-06-01	EDWARD FORFA
002	2009-06-01	EDWARD FORFA

Plan Statistics for BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN

401k plan membership statisitcs for BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN

Measure Date Value
2022: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2022 401k membership
Total participants, beginning-of-year 2022-06-01 125
Total number of active participants reported on line 7a of the Form 5500 2022-06-01 97
Number of retired or separated participants receiving benefits 2022-06-01 0
Number of other retired or separated participants entitled to future benefits 2022-06-01 5
Total of all active and inactive participants 2022-06-01 102
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-06-01 0
Total participants 2022-06-01 102
Number of participants with account balances 2022-06-01 33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-06-01 3
2021: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2021 401k membership
Total participants, beginning-of-year 2021-06-01 146
Total number of active participants reported on line 7a of the Form 5500 2021-06-01 118
Number of retired or separated participants receiving benefits 2021-06-01 0
Number of other retired or separated participants entitled to future benefits 2021-06-01 8
Total of all active and inactive participants 2021-06-01 126
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-06-01 0
Total participants 2021-06-01 126
Number of participants with account balances 2021-06-01 37
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-06-01 0
2020: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2020 401k membership
Total participants, beginning-of-year 2020-06-01 136
Total number of active participants reported on line 7a of the Form 5500 2020-06-01 137
Number of retired or separated participants receiving benefits 2020-06-01 0
Number of other retired or separated participants entitled to future benefits 2020-06-01 9
Total of all active and inactive participants 2020-06-01 146
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-06-01 0
Total participants 2020-06-01 146
Number of participants with account balances 2020-06-01 31
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-06-01 3
2019: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2019 401k membership
Total participants, beginning-of-year 2019-06-01 135
Total number of active participants reported on line 7a of the Form 5500 2019-06-01 133
Number of retired or separated participants receiving benefits 2019-06-01 0
Number of other retired or separated participants entitled to future benefits 2019-06-01 8
Total of all active and inactive participants 2019-06-01 141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-06-01 0
Total participants 2019-06-01 141
Number of participants with account balances 2019-06-01 33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-06-01 1
2018: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2018 401k membership
Total participants, beginning-of-year 2018-06-01 136
Total number of active participants reported on line 7a of the Form 5500 2018-06-01 134
Number of retired or separated participants receiving benefits 2018-06-01 0
Number of other retired or separated participants entitled to future benefits 2018-06-01 5
Total of all active and inactive participants 2018-06-01 139
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-06-01 0
Total participants 2018-06-01 139
Number of participants with account balances 2018-06-01 33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-06-01 3
2017: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2017 401k membership
Total participants, beginning-of-year 2017-06-01 134
Total number of active participants reported on line 7a of the Form 5500 2017-06-01 136
Number of retired or separated participants receiving benefits 2017-06-01 0
Number of other retired or separated participants entitled to future benefits 2017-06-01 0
Total of all active and inactive participants 2017-06-01 136
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-06-01 0
Total participants 2017-06-01 136
Number of participants with account balances 2017-06-01 29
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-06-01 0
2009: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2009 401k membership
Total participants, beginning-of-year 2009-06-01 56
Total number of active participants reported on line 7a of the Form 5500 2009-06-01 49
Number of retired or separated participants receiving benefits 2009-06-01 0
Number of other retired or separated participants entitled to future benefits 2009-06-01 0
Total of all active and inactive participants 2009-06-01 49
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-06-01 0
Total participants 2009-06-01 49
Number of participants with account balances 2009-06-01 25
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-06-01 1

Measure	Date	Value
2022: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2022 401k membership
Total participants, beginning-of-year	2022-06-01	125
Total number of active participants reported on line 7a of the Form 5500	2022-06-01	97
Number of retired or separated participants receiving benefits	2022-06-01	0
Number of other retired or separated participants entitled to future benefits	2022-06-01	5
Total of all active and inactive participants	2022-06-01	102
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-06-01	0
Total participants	2022-06-01	102
Number of participants with account balances	2022-06-01	33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-06-01	3
2021: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2021 401k membership
Total participants, beginning-of-year	2021-06-01	146
Total number of active participants reported on line 7a of the Form 5500	2021-06-01	118
Number of retired or separated participants receiving benefits	2021-06-01	0
Number of other retired or separated participants entitled to future benefits	2021-06-01	8
Total of all active and inactive participants	2021-06-01	126
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-06-01	0
Total participants	2021-06-01	126
Number of participants with account balances	2021-06-01	37
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-06-01	0
2020: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2020 401k membership
Total participants, beginning-of-year	2020-06-01	136
Total number of active participants reported on line 7a of the Form 5500	2020-06-01	137
Number of retired or separated participants receiving benefits	2020-06-01	0
Number of other retired or separated participants entitled to future benefits	2020-06-01	9
Total of all active and inactive participants	2020-06-01	146
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-06-01	0
Total participants	2020-06-01	146
Number of participants with account balances	2020-06-01	31
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-06-01	3
2019: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2019 401k membership
Total participants, beginning-of-year	2019-06-01	135
Total number of active participants reported on line 7a of the Form 5500	2019-06-01	133
Number of retired or separated participants receiving benefits	2019-06-01	0
Number of other retired or separated participants entitled to future benefits	2019-06-01	8
Total of all active and inactive participants	2019-06-01	141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-06-01	0
Total participants	2019-06-01	141
Number of participants with account balances	2019-06-01	33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-06-01	1
2018: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2018 401k membership
Total participants, beginning-of-year	2018-06-01	136
Total number of active participants reported on line 7a of the Form 5500	2018-06-01	134
Number of retired or separated participants receiving benefits	2018-06-01	0
Number of other retired or separated participants entitled to future benefits	2018-06-01	5
Total of all active and inactive participants	2018-06-01	139
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-06-01	0
Total participants	2018-06-01	139
Number of participants with account balances	2018-06-01	33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-06-01	3
2017: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2017 401k membership
Total participants, beginning-of-year	2017-06-01	134
Total number of active participants reported on line 7a of the Form 5500	2017-06-01	136
Number of retired or separated participants receiving benefits	2017-06-01	0
Number of other retired or separated participants entitled to future benefits	2017-06-01	0
Total of all active and inactive participants	2017-06-01	136
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-06-01	0
Total participants	2017-06-01	136
Number of participants with account balances	2017-06-01	29
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-06-01	0
2009: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2009 401k membership
Total participants, beginning-of-year	2009-06-01	56
Total number of active participants reported on line 7a of the Form 5500	2009-06-01	49
Number of retired or separated participants receiving benefits	2009-06-01	0
Number of other retired or separated participants entitled to future benefits	2009-06-01	0
Total of all active and inactive participants	2009-06-01	49
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-06-01	0
Total participants	2009-06-01	49
Number of participants with account balances	2009-06-01	25
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-06-01	1

Financial Data on BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN

Measure	Date	Value
2023 : BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2023 401k financial data
Unrealized appreciation/depreciation of real estate assets	2023-05-31	$0
Unrealized appreciation/depreciation of other (non real estate) assets	2023-05-31	$0
Total unrealized appreciation/depreciation of assets	2023-05-31	$0
Total transfer of assets to this plan	2023-05-31	$0
Total transfer of assets from this plan	2023-05-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2023-05-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2023-05-31	$0
Expenses. Interest paid	2023-05-31	$0
Amount of participant contributions which was failed to transmit to the plan within the time period described in 29 CFR 251.3-102	2023-05-31	$0
Total income from all sources (including contributions)	2023-05-31	$162,735
Total loss/gain on sale of assets	2023-05-31	$0
Total of all expenses incurred	2023-05-31	$146,371
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2023-05-31	$134,901
Expenses. Certain deemed distributions of participant loans	2023-05-31	$0
Value of total corrective distributions	2023-05-31	$5,544
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2023-05-31	$146,366
Value of total assets at end of year	2023-05-31	$1,749,318
Value of total assets at beginning of year	2023-05-31	$1,732,954
Total of administrative expenses incurred including professional, contract, advisory and management fees	2023-05-31	$5,926
Total income from rents	2023-05-31	$0
Total interest from all sources	2023-05-31	$702
Total dividends received (eg from common stock, registered investment company shares)	2023-05-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2023-05-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2023-05-31	$0
Assets. Real estate other than employer real property at end of year	2023-05-31	$0
Assets. Real estate other than employer real property at beginning of year	2023-05-31	$0
Administrative expenses professional fees incurred	2023-05-31	$0
Assets. Corporate prefeered stocks other than exployer securities at end of year	2023-05-31	$0
Assets. Corporate prefeered stocks other than exployer securities at beginning of year	2023-05-31	$0
Was this plan covered by a fidelity bond	2023-05-31	Yes
Value of fidelity bond cover	2023-05-31	$1,000,000
If this is an individual account plan, was there a blackout period	2023-05-31	No
Were there any nonexempt tranactions with any party-in-interest	2023-05-31	No
Contributions received from participants	2023-05-31	$103,407
Participant contributions at end of year	2023-05-31	$0
Participant contributions at beginning of year	2023-05-31	$0
Participant contributions at end of year	2023-05-31	$0
Participant contributions at beginning of year	2023-05-31	$0
Assets. Other investments not covered elsewhere at end of year	2023-05-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2023-05-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2023-05-31	$3,427
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2023-05-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2023-05-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2023-05-31	$0
Assets. Loans (other than to participants) at end of year	2023-05-31	$0
Assets. Loans (other than to participants) at beginning of year	2023-05-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2023-05-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2023-05-31	$0
Other income not declared elsewhere	2023-05-31	$0
Administrative expenses (other) incurred	2023-05-31	$0
Liabilities. Value of operating payables at end of year	2023-05-31	$0
Liabilities. Value of operating payables at beginning of year	2023-05-31	$0
Total non interest bearing cash at end of year	2023-05-31	$0
Total non interest bearing cash at beginning of year	2023-05-31	$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	2023-05-31	No
Income. Non cash contributions	2023-05-31	$0
Value of net income/loss	2023-05-31	$16,364
Value of net assets at end of year (total assets less liabilities)	2023-05-31	$1,749,318
Value of net assets at beginning of year (total assets less liabilities)	2023-05-31	$1,732,954
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2023-05-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2023-05-31	No
Were any leases to which the plan was party in default or uncollectible	2023-05-31	No
Assets. partnership/joint venture interests at end of year	2023-05-31	$0
Assets. partnership/joint venture interests at beginning of year	2023-05-31	$0
Investment advisory and management fees	2023-05-31	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2023-05-31	$1,668,828
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2023-05-31	$1,647,221
Value of interest in pooled separate accounts at end of year	2023-05-31	$0
Value of interest in pooled separate accounts at beginning of year	2023-05-31	$0
Interest on participant loans	2023-05-31	$0
Income. Interest from loans (other than to participants)	2023-05-31	$0
Interest earned on other investments	2023-05-31	$702
Income. Interest from US Government securities	2023-05-31	$0
Income. Interest from corporate debt instruments	2023-05-31	$0
Value of interest in master investment trust accounts at end of year	2023-05-31	$0
Value of interest in master investment trust accounts at beginning of year	2023-05-31	$0
Value of interest in common/collective trusts at end of year	2023-05-31	$0
Value of interest in common/collective trusts at beginning of year	2023-05-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2023-05-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2023-05-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2023-05-31	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2023-05-31	$0
Assets. Value of investments in 103.12 investment entities at end of year	2023-05-31	$0
Assets. Value of investments in 103.12 investment entities at beginning of year	2023-05-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2023-05-31	$80,490
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2023-05-31	$85,733
Expenses. Payments to insurance carriers foe the provision of benefits	2023-05-31	$0
Asset value of US Government securities at end of year	2023-05-31	$0
Asset value of US Government securities at beginning of year	2023-05-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2023-05-31	$15,667
Net investment gain/loss from pooled separate accounts	2023-05-31	$0
Net investment gain or loss from common/collective trusts	2023-05-31	$0
Net gain/loss from 103.12 investment entities	2023-05-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2023-05-31	No
Was there a failure to transmit to the plan any participant contributions	2023-05-31	No
Has the plan failed to provide any benefit when due under the plan	2023-05-31	No
Assets. Invements in employer securities at end of year	2023-05-31	$0
Assets. Invements in employer securities at beginning of year	2023-05-31	$0
Assets. Value of employer real property at end of year	2023-05-31	$0
Assets. Value of employer real property at beginning of year	2023-05-31	$0
Contributions received in cash from employer	2023-05-31	$39,532
Employer contributions (assets) at end of year	2023-05-31	$0
Employer contributions (assets) at beginning of year	2023-05-31	$0
Income. Dividends from preferred stock	2023-05-31	$0
Income. Dividends from common stock	2023-05-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2023-05-31	$134,901
Asset. Corporate debt instrument preferred debt at end of year	2023-05-31	$0
Asset. Corporate debt instrument preferred debt at beginning of year	2023-05-31	$0
Asset. Corporate debt instrument debt (other) at end of year	2023-05-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2023-05-31	$0
Contract administrator fees	2023-05-31	$5,926
Assets. Corporate common stocks other than exployer securities at end of year	2023-05-31	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2023-05-31	$0
Liabilities. Value of benefit claims payable at end of year	2023-05-31	$0
Liabilities. Value of benefit claims payable at beginning of year	2023-05-31	$0
Assets. Value of buildings and other operty used in plan operation at end of year	2023-05-31	$0
Assets. Value of buildings and other operty used in plan operation at beginning of year	2023-05-31	$0
Did the plan have assets held for investment	2023-05-31	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	2023-05-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2023-05-31	No
Aggregate proceeds on sale of assets	2023-05-31	$0
Aggregate carrying amount (costs) on sale of assets	2023-05-31	$0
Liabilities. Value of acquisition indebtedness at end of year	2023-05-31	$0
Liabilities. Value of acquisition indebtedness at beginning of year	2023-05-31	$0
Opinion of an independent qualified public accountant for this plan	2023-05-31	Unqualified
Accountancy firm name	2023-05-31	CARON & BLETZER, PLLC
Accountancy firm EIN	2023-05-31	043499945
2022 : BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2022 401k financial data
Unrealized appreciation/depreciation of real estate assets	2022-05-31	$0
Unrealized appreciation/depreciation of other (non real estate) assets	2022-05-31	$0
Total unrealized appreciation/depreciation of assets	2022-05-31	$0
Total transfer of assets to this plan	2022-05-31	$0
Total transfer of assets from this plan	2022-05-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-05-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-05-31	$0
Expenses. Interest paid	2022-05-31	$0
Amount of participant contributions which was failed to transmit to the plan within the time period described in 29 CFR 251.3-102	2022-05-31	$0
Total income from all sources (including contributions)	2022-05-31	$-43,580
Total loss/gain on sale of assets	2022-05-31	$0
Total of all expenses incurred	2022-05-31	$56,622
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-05-31	$44,141
Expenses. Certain deemed distributions of participant loans	2022-05-31	$0
Value of total corrective distributions	2022-05-31	$7,727
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-05-31	$99,457
Value of total assets at end of year	2022-05-31	$1,732,954
Value of total assets at beginning of year	2022-05-31	$1,833,156
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-05-31	$4,754
Total income from rents	2022-05-31	$0
Total interest from all sources	2022-05-31	$713
Total dividends received (eg from common stock, registered investment company shares)	2022-05-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-05-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2022-05-31	$0
Assets. Real estate other than employer real property at end of year	2022-05-31	$0
Assets. Real estate other than employer real property at beginning of year	2022-05-31	$0
Administrative expenses professional fees incurred	2022-05-31	$0
Assets. Corporate prefeered stocks other than exployer securities at end of year	2022-05-31	$0
Assets. Corporate prefeered stocks other than exployer securities at beginning of year	2022-05-31	$0
Was this plan covered by a fidelity bond	2022-05-31	Yes
Value of fidelity bond cover	2022-05-31	$1,135,927
If this is an individual account plan, was there a blackout period	2022-05-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2022-05-31	$0
Were there any nonexempt tranactions with any party-in-interest	2022-05-31	No
Contributions received from participants	2022-05-31	$65,447
Participant contributions at end of year	2022-05-31	$0
Participant contributions at beginning of year	2022-05-31	$0
Participant contributions at end of year	2022-05-31	$0
Participant contributions at beginning of year	2022-05-31	$0
Assets. Other investments not covered elsewhere at end of year	2022-05-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2022-05-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2022-05-31	$0
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2022-05-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2022-05-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2022-05-31	$0
Assets. Loans (other than to participants) at end of year	2022-05-31	$0
Assets. Loans (other than to participants) at beginning of year	2022-05-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2022-05-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2022-05-31	$0
Other income not declared elsewhere	2022-05-31	$0
Administrative expenses (other) incurred	2022-05-31	$0
Liabilities. Value of operating payables at end of year	2022-05-31	$0
Liabilities. Value of operating payables at beginning of year	2022-05-31	$0
Total non interest bearing cash at end of year	2022-05-31	$0
Total non interest bearing cash at beginning of year	2022-05-31	$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	2022-05-31	No
Income. Non cash contributions	2022-05-31	$0
Value of net income/loss	2022-05-31	$-100,202
Value of net assets at end of year (total assets less liabilities)	2022-05-31	$1,732,954
Value of net assets at beginning of year (total assets less liabilities)	2022-05-31	$1,833,156
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-05-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-05-31	No
Were any leases to which the plan was party in default or uncollectible	2022-05-31	No
Assets. partnership/joint venture interests at end of year	2022-05-31	$0
Assets. partnership/joint venture interests at beginning of year	2022-05-31	$0
Investment advisory and management fees	2022-05-31	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-05-31	$1,647,221
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-05-31	$1,744,133
Value of interest in pooled separate accounts at end of year	2022-05-31	$0
Value of interest in pooled separate accounts at beginning of year	2022-05-31	$0
Interest on participant loans	2022-05-31	$0
Income. Interest from loans (other than to participants)	2022-05-31	$0
Interest earned on other investments	2022-05-31	$713
Income. Interest from US Government securities	2022-05-31	$0
Income. Interest from corporate debt instruments	2022-05-31	$0
Value of interest in master investment trust accounts at end of year	2022-05-31	$0
Value of interest in master investment trust accounts at beginning of year	2022-05-31	$0
Value of interest in common/collective trusts at end of year	2022-05-31	$0
Value of interest in common/collective trusts at beginning of year	2022-05-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2022-05-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2022-05-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2022-05-31	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2022-05-31	$0
Assets. Value of investments in 103.12 investment entities at end of year	2022-05-31	$0
Assets. Value of investments in 103.12 investment entities at beginning of year	2022-05-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-05-31	$85,733
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-05-31	$89,023
Expenses. Payments to insurance carriers foe the provision of benefits	2022-05-31	$0
Asset value of US Government securities at end of year	2022-05-31	$0
Asset value of US Government securities at beginning of year	2022-05-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-05-31	$-143,750
Net investment gain/loss from pooled separate accounts	2022-05-31	$0
Net investment gain or loss from common/collective trusts	2022-05-31	$0
Net gain/loss from 103.12 investment entities	2022-05-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-05-31	No
Was there a failure to transmit to the plan any participant contributions	2022-05-31	No
Has the plan failed to provide any benefit when due under the plan	2022-05-31	No
Assets. Invements in employer securities at end of year	2022-05-31	$0
Assets. Invements in employer securities at beginning of year	2022-05-31	$0
Assets. Value of employer real property at end of year	2022-05-31	$0
Assets. Value of employer real property at beginning of year	2022-05-31	$0
Contributions received in cash from employer	2022-05-31	$34,010
Employer contributions (assets) at end of year	2022-05-31	$0
Employer contributions (assets) at beginning of year	2022-05-31	$0
Income. Dividends from preferred stock	2022-05-31	$0
Income. Dividends from common stock	2022-05-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-05-31	$44,141
Asset. Corporate debt instrument preferred debt at end of year	2022-05-31	$0
Asset. Corporate debt instrument preferred debt at beginning of year	2022-05-31	$0
Asset. Corporate debt instrument debt (other) at end of year	2022-05-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2022-05-31	$0
Contract administrator fees	2022-05-31	$4,754
Assets. Corporate common stocks other than exployer securities at end of year	2022-05-31	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2022-05-31	$0
Liabilities. Value of benefit claims payable at end of year	2022-05-31	$0
Liabilities. Value of benefit claims payable at beginning of year	2022-05-31	$0
Assets. Value of buildings and other operty used in plan operation at end of year	2022-05-31	$0
Assets. Value of buildings and other operty used in plan operation at beginning of year	2022-05-31	$0
Did the plan have assets held for investment	2022-05-31	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	2022-05-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-05-31	No
Aggregate proceeds on sale of assets	2022-05-31	$0
Aggregate carrying amount (costs) on sale of assets	2022-05-31	$0
Liabilities. Value of acquisition indebtedness at end of year	2022-05-31	$0
Liabilities. Value of acquisition indebtedness at beginning of year	2022-05-31	$0
Opinion of an independent qualified public accountant for this plan	2022-05-31	Unqualified
Accountancy firm name	2022-05-31	CARON & BLETZER, PLLC
Accountancy firm EIN	2022-05-31	043499945
2021 : BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2021 401k financial data
Unrealized appreciation/depreciation of real estate assets	2021-05-31	$0
Unrealized appreciation/depreciation of other (non real estate) assets	2021-05-31	$0
Total unrealized appreciation/depreciation of assets	2021-05-31	$0
Total transfer of assets to this plan	2021-05-31	$0
Total transfer of assets from this plan	2021-05-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-05-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-05-31	$0
Expenses. Interest paid	2021-05-31	$0
Amount of participant contributions which was failed to transmit to the plan within the time period described in 29 CFR 251.3-102	2021-05-31	$0
Total income from all sources (including contributions)	2021-05-31	$531,532
Total loss/gain on sale of assets	2021-05-31	$0
Total of all expenses incurred	2021-05-31	$32,394
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-05-31	$22,088
Expenses. Certain deemed distributions of participant loans	2021-05-31	$0
Value of total corrective distributions	2021-05-31	$5,514
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-05-31	$93,892
Value of total assets at end of year	2021-05-31	$1,833,156
Value of total assets at beginning of year	2021-05-31	$1,334,018
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-05-31	$4,792
Total income from rents	2021-05-31	$0
Total interest from all sources	2021-05-31	$1,307
Total dividends received (eg from common stock, registered investment company shares)	2021-05-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-05-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2021-05-31	$0
Assets. Real estate other than employer real property at end of year	2021-05-31	$0
Assets. Real estate other than employer real property at beginning of year	2021-05-31	$0
Administrative expenses professional fees incurred	2021-05-31	$0
Assets. Corporate prefeered stocks other than exployer securities at end of year	2021-05-31	$0
Assets. Corporate prefeered stocks other than exployer securities at beginning of year	2021-05-31	$0
Was this plan covered by a fidelity bond	2021-05-31	Yes
Value of fidelity bond cover	2021-05-31	$1,000,000
If this is an individual account plan, was there a blackout period	2021-05-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-05-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-05-31	No
Contributions received from participants	2021-05-31	$62,702
Participant contributions at end of year	2021-05-31	$0
Participant contributions at beginning of year	2021-05-31	$0
Participant contributions at end of year	2021-05-31	$0
Participant contributions at beginning of year	2021-05-31	$1,377
Assets. Other investments not covered elsewhere at end of year	2021-05-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2021-05-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2021-05-31	$0
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2021-05-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2021-05-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2021-05-31	$0
Assets. Loans (other than to participants) at end of year	2021-05-31	$0
Assets. Loans (other than to participants) at beginning of year	2021-05-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2021-05-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2021-05-31	$0
Other income not declared elsewhere	2021-05-31	$0
Administrative expenses (other) incurred	2021-05-31	$0
Liabilities. Value of operating payables at end of year	2021-05-31	$0
Liabilities. Value of operating payables at beginning of year	2021-05-31	$0
Total non interest bearing cash at end of year	2021-05-31	$0
Total non interest bearing cash at beginning of year	2021-05-31	$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	2021-05-31	No
Income. Non cash contributions	2021-05-31	$0
Value of net income/loss	2021-05-31	$499,138
Value of net assets at end of year (total assets less liabilities)	2021-05-31	$1,833,156
Value of net assets at beginning of year (total assets less liabilities)	2021-05-31	$1,334,018
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-05-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-05-31	No
Were any leases to which the plan was party in default or uncollectible	2021-05-31	No
Assets. partnership/joint venture interests at end of year	2021-05-31	$0
Assets. partnership/joint venture interests at beginning of year	2021-05-31	$0
Investment advisory and management fees	2021-05-31	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-05-31	$1,744,133
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-05-31	$1,221,727
Value of interest in pooled separate accounts at end of year	2021-05-31	$0
Value of interest in pooled separate accounts at beginning of year	2021-05-31	$0
Interest on participant loans	2021-05-31	$0
Income. Interest from loans (other than to participants)	2021-05-31	$0
Interest earned on other investments	2021-05-31	$1,307
Income. Interest from US Government securities	2021-05-31	$0
Income. Interest from corporate debt instruments	2021-05-31	$0
Value of interest in master investment trust accounts at end of year	2021-05-31	$0
Value of interest in master investment trust accounts at beginning of year	2021-05-31	$0
Value of interest in common/collective trusts at end of year	2021-05-31	$0
Value of interest in common/collective trusts at beginning of year	2021-05-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2021-05-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2021-05-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2021-05-31	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2021-05-31	$0
Assets. Value of investments in 103.12 investment entities at end of year	2021-05-31	$0
Assets. Value of investments in 103.12 investment entities at beginning of year	2021-05-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-05-31	$89,023
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-05-31	$94,315
Expenses. Payments to insurance carriers foe the provision of benefits	2021-05-31	$0
Asset value of US Government securities at end of year	2021-05-31	$0
Asset value of US Government securities at beginning of year	2021-05-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-05-31	$436,333
Net investment gain/loss from pooled separate accounts	2021-05-31	$0
Net investment gain or loss from common/collective trusts	2021-05-31	$0
Net gain/loss from 103.12 investment entities	2021-05-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-05-31	No
Was there a failure to transmit to the plan any participant contributions	2021-05-31	No
Has the plan failed to provide any benefit when due under the plan	2021-05-31	No
Assets. Invements in employer securities at end of year	2021-05-31	$0
Assets. Invements in employer securities at beginning of year	2021-05-31	$0
Assets. Value of employer real property at end of year	2021-05-31	$0
Assets. Value of employer real property at beginning of year	2021-05-31	$0
Contributions received in cash from employer	2021-05-31	$31,190
Employer contributions (assets) at end of year	2021-05-31	$0
Employer contributions (assets) at beginning of year	2021-05-31	$16,599
Income. Dividends from preferred stock	2021-05-31	$0
Income. Dividends from common stock	2021-05-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-05-31	$22,088
Asset. Corporate debt instrument preferred debt at end of year	2021-05-31	$0
Asset. Corporate debt instrument preferred debt at beginning of year	2021-05-31	$0
Asset. Corporate debt instrument debt (other) at end of year	2021-05-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2021-05-31	$0
Contract administrator fees	2021-05-31	$4,792
Assets. Corporate common stocks other than exployer securities at end of year	2021-05-31	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2021-05-31	$0
Liabilities. Value of benefit claims payable at end of year	2021-05-31	$0
Liabilities. Value of benefit claims payable at beginning of year	2021-05-31	$0
Assets. Value of buildings and other operty used in plan operation at end of year	2021-05-31	$0
Assets. Value of buildings and other operty used in plan operation at beginning of year	2021-05-31	$0
Did the plan have assets held for investment	2021-05-31	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	2021-05-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-05-31	No
Aggregate proceeds on sale of assets	2021-05-31	$0
Aggregate carrying amount (costs) on sale of assets	2021-05-31	$0
Liabilities. Value of acquisition indebtedness at end of year	2021-05-31	$0
Liabilities. Value of acquisition indebtedness at beginning of year	2021-05-31	$0
Opinion of an independent qualified public accountant for this plan	2021-05-31	Unqualified
Accountancy firm name	2021-05-31	CARON & BLETZER, PLLC
Accountancy firm EIN	2021-05-31	043499945
2020 : BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2020 401k financial data
Unrealized appreciation/depreciation of real estate assets	2020-05-31	$0
Unrealized appreciation/depreciation of other (non real estate) assets	2020-05-31	$0
Total unrealized appreciation/depreciation of assets	2020-05-31	$0
Total transfer of assets to this plan	2020-05-31	$0
Total transfer of assets from this plan	2020-05-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-05-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-05-31	$0
Expenses. Interest paid	2020-05-31	$0
Amount of participant contributions which was failed to transmit to the plan within the time period described in 29 CFR 251.3-102	2020-05-31	$0
Total income from all sources (including contributions)	2020-05-31	$227,587
Total loss/gain on sale of assets	2020-05-31	$0
Total of all expenses incurred	2020-05-31	$43,801
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-05-31	$37,244
Expenses. Certain deemed distributions of participant loans	2020-05-31	$0
Value of total corrective distributions	2020-05-31	$3,832
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-05-31	$144,246
Value of total assets at end of year	2020-05-31	$1,334,018
Value of total assets at beginning of year	2020-05-31	$1,150,232
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-05-31	$2,725
Total income from rents	2020-05-31	$0
Total interest from all sources	2020-05-31	$1,645
Total dividends received (eg from common stock, registered investment company shares)	2020-05-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-05-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2020-05-31	$0
Assets. Real estate other than employer real property at end of year	2020-05-31	$0
Assets. Real estate other than employer real property at beginning of year	2020-05-31	$0
Administrative expenses professional fees incurred	2020-05-31	$0
Assets. Corporate prefeered stocks other than exployer securities at end of year	2020-05-31	$0
Assets. Corporate prefeered stocks other than exployer securities at beginning of year	2020-05-31	$0
Was this plan covered by a fidelity bond	2020-05-31	Yes
Value of fidelity bond cover	2020-05-31	$1,000,000
If this is an individual account plan, was there a blackout period	2020-05-31	No
Were there any nonexempt tranactions with any party-in-interest	2020-05-31	No
Contributions received from participants	2020-05-31	$62,297
Participant contributions at end of year	2020-05-31	$0
Participant contributions at beginning of year	2020-05-31	$0
Participant contributions at end of year	2020-05-31	$1,377
Participant contributions at beginning of year	2020-05-31	$0
Assets. Other investments not covered elsewhere at end of year	2020-05-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2020-05-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2020-05-31	$48,670
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2020-05-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2020-05-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2020-05-31	$0
Assets. Loans (other than to participants) at end of year	2020-05-31	$0
Assets. Loans (other than to participants) at beginning of year	2020-05-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2020-05-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2020-05-31	$0
Other income not declared elsewhere	2020-05-31	$0
Administrative expenses (other) incurred	2020-05-31	$0
Liabilities. Value of operating payables at end of year	2020-05-31	$0
Liabilities. Value of operating payables at beginning of year	2020-05-31	$0
Total non interest bearing cash at end of year	2020-05-31	$0
Total non interest bearing cash at beginning of year	2020-05-31	$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	2020-05-31	No
Income. Non cash contributions	2020-05-31	$0
Value of net income/loss	2020-05-31	$183,786
Value of net assets at end of year (total assets less liabilities)	2020-05-31	$1,334,018
Value of net assets at beginning of year (total assets less liabilities)	2020-05-31	$1,150,232
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-05-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-05-31	No
Were any leases to which the plan was party in default or uncollectible	2020-05-31	No
Assets. partnership/joint venture interests at end of year	2020-05-31	$0
Assets. partnership/joint venture interests at beginning of year	2020-05-31	$0
Investment advisory and management fees	2020-05-31	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-05-31	$1,221,727
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-05-31	$1,047,892
Value of interest in pooled separate accounts at end of year	2020-05-31	$0
Value of interest in pooled separate accounts at beginning of year	2020-05-31	$0
Interest on participant loans	2020-05-31	$0
Income. Interest from loans (other than to participants)	2020-05-31	$0
Interest earned on other investments	2020-05-31	$1,645
Income. Interest from US Government securities	2020-05-31	$0
Income. Interest from corporate debt instruments	2020-05-31	$0
Value of interest in master investment trust accounts at end of year	2020-05-31	$0
Value of interest in master investment trust accounts at beginning of year	2020-05-31	$0
Value of interest in common/collective trusts at end of year	2020-05-31	$0
Value of interest in common/collective trusts at beginning of year	2020-05-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2020-05-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2020-05-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2020-05-31	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2020-05-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-05-31	$94,315
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-05-31	$102,340
Expenses. Payments to insurance carriers foe the provision of benefits	2020-05-31	$0
Asset value of US Government securities at end of year	2020-05-31	$0
Asset value of US Government securities at beginning of year	2020-05-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-05-31	$81,696
Net investment gain/loss from pooled separate accounts	2020-05-31	$0
Net investment gain or loss from common/collective trusts	2020-05-31	$0
Net gain/loss from 103.12 investment entities	2020-05-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-05-31	No
Was there a failure to transmit to the plan any participant contributions	2020-05-31	No
Has the plan failed to provide any benefit when due under the plan	2020-05-31	No
Assets. Invements in employer securities at end of year	2020-05-31	$0
Assets. Invements in employer securities at beginning of year	2020-05-31	$0
Assets. Value of employer real property at end of year	2020-05-31	$0
Assets. Value of employer real property at beginning of year	2020-05-31	$0
Contributions received in cash from employer	2020-05-31	$33,279
Employer contributions (assets) at end of year	2020-05-31	$16,599
Employer contributions (assets) at beginning of year	2020-05-31	$0
Income. Dividends from preferred stock	2020-05-31	$0
Income. Dividends from common stock	2020-05-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-05-31	$37,244
Asset. Corporate debt instrument preferred debt at end of year	2020-05-31	$0
Asset. Corporate debt instrument preferred debt at beginning of year	2020-05-31	$0
Asset. Corporate debt instrument debt (other) at end of year	2020-05-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2020-05-31	$0
Contract administrator fees	2020-05-31	$2,725
Assets. Corporate common stocks other than exployer securities at end of year	2020-05-31	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2020-05-31	$0
Liabilities. Value of benefit claims payable at end of year	2020-05-31	$0
Liabilities. Value of benefit claims payable at beginning of year	2020-05-31	$0
Assets. Value of buildings and other operty used in plan operation at end of year	2020-05-31	$0
Assets. Value of buildings and other operty used in plan operation at beginning of year	2020-05-31	$0
Did the plan have assets held for investment	2020-05-31	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	2020-05-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-05-31	No
Aggregate proceeds on sale of assets	2020-05-31	$0
Aggregate carrying amount (costs) on sale of assets	2020-05-31	$0
Liabilities. Value of acquisition indebtedness at end of year	2020-05-31	$0
Liabilities. Value of acquisition indebtedness at beginning of year	2020-05-31	$0
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2020-05-31	Yes
Opinion of an independent qualified public accountant for this plan	2020-05-31	Disclaimer
Accountancy firm name	2020-05-31	CARON & BLETZER, PLLC
Accountancy firm EIN	2020-05-31	043499945
2019 : BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2019 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-05-31	$0
2018 : BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-05-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-05-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-05-31	$0
Total income from all sources (including contributions)	2018-05-31	$198,520
Total loss/gain on sale of assets	2018-05-31	$0
Total of all expenses incurred	2018-05-31	$23,517
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-05-31	$23,222
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-05-31	$93,011
Value of total assets at end of year	2018-05-31	$1,272,722
Value of total assets at beginning of year	2018-05-31	$1,097,719
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-05-31	$295
Total interest from all sources	2018-05-31	$2,360
Total dividends received (eg from common stock, registered investment company shares)	2018-05-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-05-31	No
Was this plan covered by a fidelity bond	2018-05-31	Yes
Value of fidelity bond cover	2018-05-31	$100,000
If this is an individual account plan, was there a blackout period	2018-05-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-05-31	$0
Were there any nonexempt tranactions with any party-in-interest	2018-05-31	No
Contributions received from participants	2018-05-31	$58,835
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-05-31	No
Value of net income/loss	2018-05-31	$175,003
Value of net assets at end of year (total assets less liabilities)	2018-05-31	$1,272,722
Value of net assets at beginning of year (total assets less liabilities)	2018-05-31	$1,097,719
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-05-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-05-31	No
Were any leases to which the plan was party in default or uncollectible	2018-05-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2018-05-31	$1,170,905
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2018-05-31	$974,126
Interest earned on other investments	2018-05-31	$2,360
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2018-05-31	$101,817
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2018-05-31	$123,593
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-05-31	$103,149
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-05-31	No
Was there a failure to transmit to the plan any participant contributions	2018-05-31	No
Has the plan failed to provide any benefit when due under the plan	2018-05-31	No
Contributions received in cash from employer	2018-05-31	$34,176
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-05-31	$23,222
Contract administrator fees	2018-05-31	$295
Did the plan have assets held for investment	2018-05-31	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	2018-05-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-05-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-05-31	Yes
Opinion of an independent qualified public accountant for this plan	2018-05-31	Disclaimer
Accountancy firm name	2018-05-31	ADELSON & COMPANY PC
Accountancy firm EIN	2018-05-31	205711238
2010 : BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2010 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-05-31	$0

Form 5500 Responses for BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN

2022: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2022 form 5500 responses
2022-06-01	Type of plan entity	Single employer plan
2022-06-01	Submission has been amended	No
2022-06-01	This submission is the final filing	No
2022-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-06-01	Plan is a collectively bargained plan	No
2022-06-01	Plan funding arrangement – Insurance	Yes
2022-06-01	Plan benefit arrangement - Trust	Yes
2021: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2021 form 5500 responses
2021-06-01	Type of plan entity	Single employer plan
2021-06-01	Submission has been amended	No
2021-06-01	This submission is the final filing	No
2021-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-06-01	Plan is a collectively bargained plan	No
2021-06-01	Plan funding arrangement – Insurance	Yes
2021-06-01	Plan benefit arrangement - Trust	Yes
2020: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2020 form 5500 responses
2020-06-01	Type of plan entity	Single employer plan
2020-06-01	Submission has been amended	No
2020-06-01	This submission is the final filing	No
2020-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-06-01	Plan is a collectively bargained plan	No
2020-06-01	Plan funding arrangement – Insurance	Yes
2020-06-01	Plan benefit arrangement - Trust	Yes
2019: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2019 form 5500 responses
2019-06-01	Type of plan entity	Single employer plan
2019-06-01	Submission has been amended	Yes
2019-06-01	This submission is the final filing	No
2019-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-06-01	Plan is a collectively bargained plan	No
2019-06-01	Plan funding arrangement – Insurance	Yes
2019-06-01	Plan benefit arrangement - Trust	Yes
2018: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2018 form 5500 responses
2018-06-01	Type of plan entity	Single employer plan
2018-06-01	Submission has been amended	No
2018-06-01	This submission is the final filing	No
2018-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-06-01	Plan is a collectively bargained plan	No
2018-06-01	Plan funding arrangement – Insurance	Yes
2018-06-01	Plan benefit arrangement - Trust	Yes
2017: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2017 form 5500 responses
2017-06-01	Type of plan entity	Single employer plan
2017-06-01	Submission has been amended	Yes
2017-06-01	This submission is the final filing	No
2017-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-06-01	Plan is a collectively bargained plan	No
2017-06-01	Plan funding arrangement – Insurance	Yes
2017-06-01	Plan benefit arrangement - Trust	Yes
2009: BERKSHIRE RETIREMENT HOME, INC. 403(B) PLAN 2009 form 5500 responses
2009-06-01	Type of plan entity	Single employer plan
2009-06-01	Submission has been amended	No
2009-06-01	This submission is the final filing	No
2009-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-06-01	Plan is a collectively bargained plan	No
2009-06-01	Plan funding arrangement – Trust	Yes
2009-06-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

WELLS FARGO ADVISORS INS AGENCY LLC (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VFB315

Policy instance

Insurance contract or identification number	VFB315
Number of Individuals Covered	1
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $1
Total amount of fees paid to insurance company	USD $0
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G76840

Policy instance

Insurance contract or identification number	G76840
Number of Individuals Covered	33
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
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?	Yes
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

WELLS FARGO ADVISORS INS AGENCY LLC (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VFB315

Policy instance

Insurance contract or identification number	VFB315
Number of Individuals Covered	4
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $16
Total amount of fees paid to insurance company	USD $0
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G76840

Policy instance

Insurance contract or identification number	G76840
Number of Individuals Covered	37
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
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?	Yes
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

WELLS FARGO ADVISORS INS AGENCY LLC (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VFB315

Policy instance

Insurance contract or identification number	VFB315
Number of Individuals Covered	4
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $61
Total amount of fees paid to insurance company	USD $0
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?	Yes
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 $61
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G76840

Policy instance

Insurance contract or identification number	G76840
Number of Individuals Covered	31
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
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?	Yes
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

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VFB315

Policy instance

Insurance contract or identification number	VFB315
Number of Individuals Covered	6
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $111
Total amount of fees paid to insurance company	USD $0
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?	Yes
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 $111
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G76840

Policy instance

Insurance contract or identification number	G76840
Number of Individuals Covered	33
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
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?	Yes
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

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VFB315

Policy instance

Insurance contract or identification number	VFB315
Number of Individuals Covered	8
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $413
Total amount of fees paid to insurance company	USD $0
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?	Yes
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 $410
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G76840

Policy instance

Insurance contract or identification number	G76840
Number of Individuals Covered	33
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
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?	Yes
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

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VFB315

Policy instance

Insurance contract or identification number	VFB315
Number of Individuals Covered	32
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $2,942
Total amount of fees paid to insurance company	USD $0
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	BERKSHIRE RETIREMENT HOME, INC.
Employer identification number (EIN):	042103875
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities