401k Plan data: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN plan

BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 401k Plan overview

Plan Name	BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN
Plan identification number	002

BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY 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.
Partial participant-directed account plan - Participants have the opportunity to direct the investment of a portion of 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.
Code section 403(b)(1) arrangement - See Limited Pension Plan Reporting instructions for Code section 403(b)(1) arrangements for certain exempt organizations.
Participant-directed brokerage accounts provided as an investment option under the plan.

401k Sponsoring company profile

BARNESVILLE HOSPITAL ASSOCIATION INC. has sponsored the creation of one or more 401k plans.

Company Name: BARNESVILLE HOSPITAL ASSOCIATION INC.

Employer identification number (EIN): 340719172

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2022-01-01
002 2022-01-01
002 2021-01-01
002 2020-01-01
002 2020-01-01
002 2019-01-01
002 2018-01-01
002 2018-01-01

Plan Statistics for BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN

401k plan membership statisitcs for BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN

Measure Date Value
2022: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 254
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 198
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 71
Total of all active and inactive participants 2022-01-01 269
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 269
Number of participants with account balances 2022-01-01 189
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 24
2021: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 253
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 203
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 42
Total of all active and inactive participants 2021-01-01 245
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 245
Number of participants with account balances 2021-01-01 181
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0
2020: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 260
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 228
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 22
Total of all active and inactive participants 2020-01-01 250
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 250
Number of participants with account balances 2020-01-01 191
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 271
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 243
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 19
Total of all active and inactive participants 2019-01-01 262
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 262
Number of participants with account balances 2019-01-01 178
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 4
2018: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 263
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 257
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 13
Total of all active and inactive participants 2018-01-01 270
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 270
Number of participants with account balances 2018-01-01 189
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 0

Measure	Date	Value
2022: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	254
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	198
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	71
Total of all active and inactive participants	2022-01-01	269
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	269
Number of participants with account balances	2022-01-01	189
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	24
2021: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	253
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	203
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	42
Total of all active and inactive participants	2021-01-01	245
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	245
Number of participants with account balances	2021-01-01	181
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
2020: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	260
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	228
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	22
Total of all active and inactive participants	2020-01-01	250
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	250
Number of participants with account balances	2020-01-01	191
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	271
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	243
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	19
Total of all active and inactive participants	2019-01-01	262
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	262
Number of participants with account balances	2019-01-01	178
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	4
2018: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	263
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	257
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	13
Total of all active and inactive participants	2018-01-01	270
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	270
Number of participants with account balances	2018-01-01	189
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	0

Financial Data on BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN

Measure	Date	Value
2022 : BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$193
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total income from all sources (including contributions)	2022-12-31	$-120,921
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$813,531
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$800,385
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$492,254
Value of total assets at end of year	2022-12-31	$3,744,079
Value of total assets at beginning of year	2022-12-31	$4,678,338
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$13,146
Total interest from all sources	2022-12-31	$502
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$0
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	$400,903
Participant contributions at end of year	2022-12-31	$0
Participant contributions at beginning of year	2022-12-31	$12,213
Assets. Loans (other than to participants) at end of year	2022-12-31	$16,128
Assets. Loans (other than to participants) at beginning of year	2022-12-31	$18,351
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2022-12-31	$193
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2022-12-31	$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	2022-12-31	No
Value of net income/loss	2022-12-31	$-934,452
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$3,743,886
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$4,678,338
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	$2,648,210
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$3,378,023
Value of interest in pooled separate accounts at end of year	2022-12-31	$249,046
Value of interest in pooled separate accounts at beginning of year	2022-12-31	$433,509
Interest on participant loans	2022-12-31	$502
Interest earned on other investments	2022-12-31	$121,691
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-12-31	$830,695
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-12-31	$832,742
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-613,677
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	$91,351
Employer contributions (assets) at end of year	2022-12-31	$0
Employer contributions (assets) at beginning of year	2022-12-31	$3,500
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$800,385
Contract administrator fees	2022-12-31	$13,146
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	Disclaimer
Accountancy firm name	2022-12-31	BLUE & CO., LLC
Accountancy firm EIN	2022-12-31	351178661
2021 : BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$1,063,600
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$763,612
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$709,768
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$538,722
Value of total assets at end of year	2021-12-31	$4,678,338
Value of total assets at beginning of year	2021-12-31	$4,378,350
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$53,844
Total interest from all sources	2021-12-31	$36,803
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$0
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
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$438,897
Participant contributions at end of year	2021-12-31	$12,213
Participant contributions at beginning of year	2021-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$4,951
Assets. Loans (other than to participants) at end of year	2021-12-31	$18,351
Assets. Loans (other than to participants) at beginning of year	2021-12-31	$19,795
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	$299,988
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$4,678,338
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$4,378,350
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	$3,378,023
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$2,982,771
Value of interest in pooled separate accounts at end of year	2021-12-31	$433,509
Value of interest in pooled separate accounts at beginning of year	2021-12-31	$379,184
Interest on participant loans	2021-12-31	$1,009
Interest earned on other investments	2021-12-31	$35,794
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-12-31	$832,742
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-12-31	$996,600
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$488,075
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	$94,874
Employer contributions (assets) at end of year	2021-12-31	$3,500
Employer contributions (assets) at beginning of year	2021-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$709,768
Contract administrator fees	2021-12-31	$53,844
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	Disclaimer
Accountancy firm name	2021-12-31	BLUE & CO., LLC
Accountancy firm EIN	2021-12-31	351178661
2020 : BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$1,096,829
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$448,703
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$405,515
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$567,072
Value of total assets at end of year	2020-12-31	$4,378,350
Value of total assets at beginning of year	2020-12-31	$3,730,224
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$43,188
Total interest from all sources	2020-12-31	$42,871
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$0
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
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2020-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$434,000
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$68,647
Assets. Loans (other than to participants) at end of year	2020-12-31	$19,795
Assets. Loans (other than to participants) at beginning of year	2020-12-31	$21,687
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	$648,126
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$4,378,350
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$3,730,224
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	$2,982,771
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$2,099,012
Value of interest in pooled separate accounts at end of year	2020-12-31	$379,184
Value of interest in pooled separate accounts at beginning of year	2020-12-31	$325,857
Interest on participant loans	2020-12-31	$1,055
Interest earned on other investments	2020-12-31	$41,816
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-12-31	$996,600
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-12-31	$1,283,668
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$486,886
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	$64,425
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$405,515
Contract administrator fees	2020-12-31	$43,188
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	Unqualified
Accountancy firm name	2020-12-31	BLUE & CO., LLC
Accountancy firm EIN	2020-12-31	351178661
2019 : BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total income from all sources (including contributions)	2019-12-31	$1,096,821
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$774,133
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$652,287
Value of total corrective distributions	2019-12-31	$88,855
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$607,740
Value of total assets at end of year	2019-12-31	$3,730,224
Value of total assets at beginning of year	2019-12-31	$3,407,536
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$32,991
Total interest from all sources	2019-12-31	$41,901
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$0
Assets. Real estate other than employer real property at end of year	2019-12-31	$0
Assets. Real estate other than employer real property at beginning of year	2019-12-31	$0
Administrative expenses professional fees incurred	2019-12-31	$32,991
Assets. Corporate prefeered stocks other than exployer securities at end of year	2019-12-31	$0
Assets. Corporate prefeered stocks other than exployer securities at beginning of year	2019-12-31	$0
Was this plan covered by a fidelity bond	2019-12-31	Yes
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
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
Contributions received from participants	2019-12-31	$499,010
Participant contributions at end of year	2019-12-31	$0
Participant contributions at beginning of year	2019-12-31	$0
Participant contributions at end of year	2019-12-31	$0
Participant contributions at beginning of year	2019-12-31	$0
Assets. Other investments not covered elsewhere at end of year	2019-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2019-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$3,723
Value of other receiveables (less allowance for doubtful accounts) at end of year	2019-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2019-12-31	$0
Assets. Loans (other than to participants) at end of year	2019-12-31	$21,687
Assets. Loans (other than to participants) at beginning of year	2019-12-31	$2,867
Total non interest bearing cash at end of year	2019-12-31	$0
Total non interest bearing cash at beginning of year	2019-12-31	$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	2019-12-31	No
Value of net income/loss	2019-12-31	$322,688
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$3,730,224
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$3,407,536
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 leases to which the plan was party in default or uncollectible	2019-12-31	No
Assets. partnership/joint venture interests at end of year	2019-12-31	$0
Assets. partnership/joint venture interests at beginning of year	2019-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$2,099,012
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$1,401,622
Value of interest in pooled separate accounts at end of year	2019-12-31	$325,857
Value of interest in pooled separate accounts at beginning of year	2019-12-31	$601,373
Interest on participant loans	2019-12-31	$348
Value of interest in master investment trust accounts at end of year	2019-12-31	$0
Value of interest in master investment trust accounts at beginning of year	2019-12-31	$0
Value of interest in common/collective trusts at end of year	2019-12-31	$0
Value of interest in common/collective trusts at beginning of year	2019-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2019-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2019-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2019-12-31	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2019-12-31	$41,553
Assets. Value of investments in 103.12 investment entities at end of year	2019-12-31	$0
Assets. Value of investments in 103.12 investment entities at beginning of year	2019-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-12-31	$1,283,668
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$1,401,674
Asset value of US Government securities at end of year	2019-12-31	$0
Asset value of US Government securities at beginning of year	2019-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$447,180
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
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Assets. Invements in employer securities at end of year	2019-12-31	$0
Assets. Invements in employer securities at beginning of year	2019-12-31	$0
Assets. Value of employer real property at end of year	2019-12-31	$0
Assets. Value of employer real property at beginning of year	2019-12-31	$0
Contributions received in cash from employer	2019-12-31	$105,007
Employer contributions (assets) at end of year	2019-12-31	$0
Employer contributions (assets) at beginning of year	2019-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$652,287
Asset. Corporate debt instrument preferred debt at end of year	2019-12-31	$0
Asset. Corporate debt instrument preferred debt at beginning of year	2019-12-31	$0
Asset. Corporate debt instrument debt (other) at end of year	2019-12-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2019-12-31	$0
Assets. Corporate common stocks other than exployer securities at end of year	2019-12-31	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2019-12-31	$0
Assets. Value of buildings and other operty used in plan operation at end of year	2019-12-31	$0
Assets. Value of buildings and other operty used in plan operation at beginning of year	2019-12-31	$0
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
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
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Accountancy firm name	2019-12-31	BLUE & CO., LLC
Accountancy firm EIN	2019-12-31	351178661
2018 : BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-12-31	$0
Total transfer of assets to this plan	2018-12-31	$160,657
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total income from all sources (including contributions)	2018-12-31	$454,497
Total loss/gain on sale of assets	2018-12-31	$0
Total of all expenses incurred	2018-12-31	$237,484
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$215,161
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$531,152
Value of total assets at end of year	2018-12-31	$3,407,536
Value of total assets at beginning of year	2018-12-31	$3,029,866
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$22,323
Total interest from all sources	2018-12-31	$51,787
Total dividends received (eg from common stock, registered investment company shares)	2018-12-31	$0
Assets. Real estate other than employer real property at end of year	2018-12-31	$0
Assets. Real estate other than employer real property at beginning of year	2018-12-31	$0
Administrative expenses professional fees incurred	2018-12-31	$22,323
Assets. Corporate prefeered stocks other than exployer securities at end of year	2018-12-31	$0
Assets. Corporate prefeered stocks other than exployer securities at beginning of year	2018-12-31	$0
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$500,000
If this is an individual account plan, was there a blackout period	2018-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Contributions received from participants	2018-12-31	$408,105
Participant contributions at end of year	2018-12-31	$0
Participant contributions at beginning of year	2018-12-31	$0
Participant contributions at end of year	2018-12-31	$0
Participant contributions at beginning of year	2018-12-31	$0
Assets. Other investments not covered elsewhere at end of year	2018-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2018-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2018-12-31	$53,074
Value of other receiveables (less allowance for doubtful accounts) at end of year	2018-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2018-12-31	$0
Assets. Loans (other than to participants) at end of year	2018-12-31	$2,867
Assets. Loans (other than to participants) at beginning of year	2018-12-31	$6,740
Total non interest bearing cash at end of year	2018-12-31	$0
Total non interest bearing cash at beginning of year	2018-12-31	$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	2018-12-31	No
Income. Non cash contributions	2018-12-31	$0
Value of net income/loss	2018-12-31	$217,013
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$3,407,536
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$3,029,866
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-12-31	No
Were any leases to which the plan was party in default or uncollectible	2018-12-31	No
Assets. partnership/joint venture interests at end of year	2018-12-31	$0
Assets. partnership/joint venture interests at beginning of year	2018-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2018-12-31	$1,401,622
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2018-12-31	$104,159
Value of interest in pooled separate accounts at end of year	2018-12-31	$601,373
Value of interest in pooled separate accounts at beginning of year	2018-12-31	$1,189,722
Value of interest in master investment trust accounts at end of year	2018-12-31	$0
Value of interest in master investment trust accounts at beginning of year	2018-12-31	$0
Value of interest in common/collective trusts at end of year	2018-12-31	$0
Value of interest in common/collective trusts at beginning of year	2018-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2018-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2018-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2018-12-31	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2018-12-31	$51,787
Assets. Value of investments in 103.12 investment entities at end of year	2018-12-31	$0
Assets. Value of investments in 103.12 investment entities at beginning of year	2018-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2018-12-31	$1,401,674
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2018-12-31	$1,729,245
Asset value of US Government securities at end of year	2018-12-31	$0
Asset value of US Government securities at beginning of year	2018-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-12-31	$-128,442
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-12-31	No
Was there a failure to transmit to the plan any participant contributions	2018-12-31	No
Has the plan failed to provide any benefit when due under the plan	2018-12-31	No
Assets. Invements in employer securities at end of year	2018-12-31	$0
Assets. Invements in employer securities at beginning of year	2018-12-31	$0
Assets. Value of employer real property at end of year	2018-12-31	$0
Assets. Value of employer real property at beginning of year	2018-12-31	$0
Contributions received in cash from employer	2018-12-31	$69,973
Employer contributions (assets) at end of year	2018-12-31	$0
Employer contributions (assets) at beginning of year	2018-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$215,161
Asset. Corporate debt instrument preferred debt at end of year	2018-12-31	$0
Asset. Corporate debt instrument preferred debt at beginning of year	2018-12-31	$0
Asset. Corporate debt instrument debt (other) at end of year	2018-12-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2018-12-31	$0
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2018-12-31	No
Assets. Corporate common stocks other than exployer securities at end of year	2018-12-31	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2018-12-31	$0
Assets. Value of buildings and other operty used in plan operation at end of year	2018-12-31	$0
Assets. Value of buildings and other operty used in plan operation at beginning of year	2018-12-31	$0
Did the plan have assets held for investment	2018-12-31	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	2018-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2018-12-31	Disclaimer
Accountancy firm name	2018-12-31	BLUE & CO., LLC
Accountancy firm EIN	2018-12-31	351178661

Form 5500 Responses for BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN

2022: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
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: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
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: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
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: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
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
2018: BARNESVILLE HOSPITAL ASSOCIATION, INC. VOLUNTARY TAX DEFERRED ANNUITY PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	First time form 5500 has been submitted	Yes
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	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

GAP-B2-KU1T

Policy instance

Insurance contract or identification number	GAP-B2-KU1T
Number of Individuals Covered	2
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	Yes
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

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

750983

Policy instance

Insurance contract or identification number	750983
Number of Individuals Covered	9
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

JG76

Policy instance

Insurance contract or identification number	JG76
Number of Individuals Covered	21
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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

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

Policy contract number

GAP-B2-KU1T

Policy instance

Insurance contract or identification number	GAP-B2-KU1T
Number of Individuals Covered	3
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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?	Yes
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

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

750983

Policy instance

Insurance contract or identification number	750983
Number of Individuals Covered	13
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

JG76

Policy instance

Insurance contract or identification number	JG76
Number of Individuals Covered	21
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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

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

Policy contract number

GAP-B2-KU1T

Policy instance

Insurance contract or identification number	GAP-B2-KU1T
Number of Individuals Covered	3
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

750983

Policy instance

Insurance contract or identification number	750983
Number of Individuals Covered	14
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

JG76

Policy instance

Insurance contract or identification number	JG76
Number of Individuals Covered	25
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

750983

Policy instance

Insurance contract or identification number	750983
Number of Individuals Covered	14
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,762
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 $0
Amount paid for insurance broker fees	1762
Additional information about fees paid to insurance broker	INVESTMENT FEES
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

JG76

Policy instance

Insurance contract or identification number	JG76
Number of Individuals Covered	27
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
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

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

750983

Policy instance

Insurance contract or identification number	750983
Number of Individuals Covered	17
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $3,590
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
Amount paid for insurance broker fees	3590
Additional information about fees paid to insurance broker	INVESTMENT FEES
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

JG76

Policy instance

Insurance contract or identification number	JG76
Number of Individuals Covered	29
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
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

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Company Name:	BARNESVILLE HOSPITAL ASSOCIATION INC.
Employer identification number (EIN):	340719172
NAIC Classification:	622000
NAIC Description:	Hospitals