401k Plan data: OMELAGAH, INC. RETIREMENT PLAN plan

OMELAGAH, INC. RETIREMENT PLAN 401k Plan overview

Plan Name	OMELAGAH, INC. RETIREMENT PLAN
Plan identification number	001

OMELAGAH, INC. RETIREMENT PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

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

401k Sponsoring company profile

OMELAGAH, INC. has sponsored the creation of one or more 401k plans.

Company Name: OMELAGAH, INC.

Employer identification number (EIN): 272027310

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan OMELAGAH, INC. RETIREMENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01
001 2021-01-01
001 2020-01-01
001 2019-01-01
001 2018-01-01 EBONY OMELAGAH 2019-07-19
001 2017-01-01 EBONY OMELAGAH 2018-06-12

Plan Statistics for OMELAGAH, INC. RETIREMENT PLAN

401k plan membership statisitcs for OMELAGAH, INC. RETIREMENT PLAN

Measure Date Value
2022: OMELAGAH, INC. RETIREMENT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 117
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 101
Number of retired or separated participants receiving benefits 2022-01-01 2
Number of other retired or separated participants entitled to future benefits 2022-01-01 9
Total of all active and inactive participants 2022-01-01 112
Total participants 2022-01-01 112
Number of participants with account balances 2022-01-01 44
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 0
2021: OMELAGAH, INC. RETIREMENT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 133
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 102
Number of retired or separated participants receiving benefits 2021-01-01 2
Number of other retired or separated participants entitled to future benefits 2021-01-01 13
Total of all active and inactive participants 2021-01-01 117
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 117
Number of participants with account balances 2021-01-01 55
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0
2020: OMELAGAH, INC. RETIREMENT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 132
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 122
Number of retired or separated participants receiving benefits 2020-01-01 1
Number of other retired or separated participants entitled to future benefits 2020-01-01 10
Total of all active and inactive participants 2020-01-01 133
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 133
Number of participants with account balances 2020-01-01 52
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: OMELAGAH, INC. RETIREMENT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 127
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 123
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 9
Total of all active and inactive participants 2019-01-01 132
Total participants 2019-01-01 132
Number of participants with account balances 2019-01-01 51

Measure	Date	Value
2022: OMELAGAH, INC. RETIREMENT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	117
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	101
Number of retired or separated participants receiving benefits	2022-01-01	2
Number of other retired or separated participants entitled to future benefits	2022-01-01	9
Total of all active and inactive participants	2022-01-01	112
Total participants	2022-01-01	112
Number of participants with account balances	2022-01-01	44
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	0
2021: OMELAGAH, INC. RETIREMENT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	133
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	102
Number of retired or separated participants receiving benefits	2021-01-01	2
Number of other retired or separated participants entitled to future benefits	2021-01-01	13
Total of all active and inactive participants	2021-01-01	117
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	117
Number of participants with account balances	2021-01-01	55
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
2020: OMELAGAH, INC. RETIREMENT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	132
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	122
Number of retired or separated participants receiving benefits	2020-01-01	1
Number of other retired or separated participants entitled to future benefits	2020-01-01	10
Total of all active and inactive participants	2020-01-01	133
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	133
Number of participants with account balances	2020-01-01	52
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: OMELAGAH, INC. RETIREMENT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	127
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	123
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	9
Total of all active and inactive participants	2019-01-01	132
Total participants	2019-01-01	132
Number of participants with account balances	2019-01-01	51

Financial Data on OMELAGAH, INC. RETIREMENT PLAN

Measure	Date	Value
2022 : OMELAGAH, INC. RETIREMENT PLAN 2022 401k financial data
Total income from all sources (including contributions)	2022-12-31	$-140
Total of all expenses incurred	2022-12-31	$132,861
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$132,861
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$250,481
Value of total assets at end of year	2022-12-31	$1,229,899
Value of total assets at beginning of year	2022-12-31	$1,362,900
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$500,000
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$177,783
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-133,001
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$1,229,899
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$1,362,900
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$1,190,206
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$1,329,915
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-12-31	$39,693
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-12-31	$32,985
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-250,621
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$72,698
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$132,861
Did the plan have assets held for investment	2022-12-31	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	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	LANTAN AND ASSOCIATES
Accountancy firm EIN	2022-12-31	923971331
2021 : OMELAGAH, INC. RETIREMENT PLAN 2021 401k financial data
Total income from all sources (including contributions)	2021-12-31	$389,837
Total of all expenses incurred	2021-12-31	$21,098
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$21,098
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$247,972
Value of total assets at end of year	2021-12-31	$1,362,900
Value of total assets at beginning of year	2021-12-31	$994,161
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$500,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$164,192
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$11,929
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$368,739
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$1,362,900
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$994,161
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$1,329,915
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$973,530
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-12-31	$32,985
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-12-31	$20,631
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$141,865
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$71,851
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$21,098
Did the plan have assets held for investment	2021-12-31	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	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	BUCKLEY PATCHEN
Accountancy firm EIN	2021-12-31	942302150
2020 : OMELAGAH, INC. RETIREMENT PLAN 2020 401k financial data
Total income from all sources (including contributions)	2020-12-31	$350,693
Total of all expenses incurred	2020-12-31	$30,329
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$30,329
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$243,660
Value of total assets at end of year	2020-12-31	$994,161
Value of total assets at beginning of year	2020-12-31	$673,797
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$500,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$160,081
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$13,765
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$320,364
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$994,161
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$673,797
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-12-31	$973,530
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$670,512
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-12-31	$20,631
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-12-31	$3,285
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$107,033
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	No
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$69,814
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$30,329
Did the plan have assets held for investment	2020-12-31	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	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Disclaimer
Accountancy firm name	2020-12-31	BUCKLEY PATCHEN
Accountancy firm EIN	2020-12-31	202302150
2019 : OMELAGAH, INC. RETIREMENT PLAN 2019 401k financial data
Total income from all sources (including contributions)	2019-12-31	$323,833
Total income from all sources (including contributions)	2019-12-31	$323,833
Total of all expenses incurred	2019-12-31	$12,786
Total of all expenses incurred	2019-12-31	$12,786
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$12,786
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$12,786
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$229,423
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$229,423
Value of total assets at end of year	2019-12-31	$673,797
Value of total assets at end of year	2019-12-31	$673,797
Value of total assets at beginning of year	2019-12-31	$362,750
Value of total assets at beginning of year	2019-12-31	$362,750
Total interest from all sources	2019-12-31	$35
Total interest from all sources	2019-12-31	$35
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Was this plan covered by a fidelity bond	2019-12-31	Yes
Was this plan covered by a fidelity bond	2019-12-31	Yes
Value of fidelity bond cover	2019-12-31	$500,000
Value of fidelity bond cover	2019-12-31	$500,000
If this is an individual account plan, was there a blackout period	2019-12-31	No
If this is an individual account plan, was there a blackout period	2019-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Contributions received from participants	2019-12-31	$149,215
Contributions received from participants	2019-12-31	$149,215
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$11,504
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$11,504
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	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	2019-12-31	No
Value of net income/loss	2019-12-31	$311,047
Value of net income/loss	2019-12-31	$311,047
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$673,797
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$673,797
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$362,750
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$362,750
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$670,512
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$670,512
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$361,129
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$361,129
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2019-12-31	$35
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2019-12-31	$35
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-12-31	$3,285
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-12-31	$3,285
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$1,621
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$1,621
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$94,375
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$94,375
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Contributions received in cash from employer	2019-12-31	$68,704
Contributions received in cash from employer	2019-12-31	$68,704
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$12,786
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$12,786
Did the plan have assets held for investment	2019-12-31	Yes
Did the plan have assets held for investment	2019-12-31	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	2019-12-31	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	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Accountancy firm name	2019-12-31	BUCKLEY PATCHEN
Accountancy firm name	2019-12-31	BUCKLEY PATCHEN
Accountancy firm EIN	2019-12-31	202302150
Accountancy firm EIN	2019-12-31	202302150

Form 5500 Responses for OMELAGAH, INC. RETIREMENT PLAN

2022: OMELAGAH, INC. RETIREMENT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: OMELAGAH, INC. RETIREMENT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: OMELAGAH, INC. RETIREMENT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: OMELAGAH, INC. RETIREMENT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

Policy instance

Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $157
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	157
Insurance broker organization code?	7

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

Policy instance

Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $137
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	137
Insurance broker organization code?	7

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

Policy instance

Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of fees paid to insurance company	USD $38
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	38
Insurance broker organization code?	7

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

Policy instance

Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of fees paid to insurance company	USD $12
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	12
Insurance broker organization code?	7

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Company Name:	OMELAGAH, INC.
Employer identification number (EIN):	272027310
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities