401k Plan data: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN plan

BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 401k Plan overview

Plan Name	BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN
Plan identification number	012

BUCYRUS COMMUNITY HOSPITAL 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.
Code section 403(b)(1) arrangement - See Limited Pension Plan Reporting instructions for Code section 403(b)(1) arrangements for certain exempt organizations.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

BUCYRUS COMMUNITY HOSPITAL INC. has sponsored the creation of one or more 401k plans.

Company Name: BUCYRUS COMMUNITY HOSPITAL INC.

Employer identification number (EIN): 344468311

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
012 2010-01-01 JEANNE PERKINS JEANNE PERKINS 2011-09-01
012 2009-01-01 JEANNE PERKINS JEANNE PERKINS 2010-12-28
012 2008-01-01 JEANNE PERKINS JEANNE PERKINS 2010-12-28
012 2007-01-01 JEANNE PERKINS JEANNE PERKINS 2010-12-28
012 2006-01-01 JEANNE PERKINS JEANNE PERKINS 2010-12-28
012 2005-01-01 JEANNE PERKINS JEANNE PERKINS 2010-12-28
012 2004-01-01 JEANNE PERKINS JEANNE PERKINS 2010-12-28
012 2003-01-01 JEANNE PERKINS JEANNE PERKINS 2010-12-28
012 2002-01-01 JEANNE PERKINS JEANNE PERKINS 2010-12-28
012 2001-02-01 JEANNE PERKINS JEANNE PERKINS 2010-12-28

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
012	2010-01-01	JEANNE PERKINS	JEANNE PERKINS	2011-09-01
012	2009-01-01	JEANNE PERKINS	JEANNE PERKINS	2010-12-28
012	2008-01-01	JEANNE PERKINS	JEANNE PERKINS	2010-12-28
012	2007-01-01	JEANNE PERKINS	JEANNE PERKINS	2010-12-28
012	2006-01-01	JEANNE PERKINS	JEANNE PERKINS	2010-12-28
012	2005-01-01	JEANNE PERKINS	JEANNE PERKINS	2010-12-28
012	2004-01-01	JEANNE PERKINS	JEANNE PERKINS	2010-12-28
012	2003-01-01	JEANNE PERKINS	JEANNE PERKINS	2010-12-28
012	2002-01-01	JEANNE PERKINS	JEANNE PERKINS	2010-12-28
012	2001-02-01	JEANNE PERKINS	JEANNE PERKINS	2010-12-28

Plan Statistics for BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN

401k plan membership statisitcs for BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN

Measure Date Value
2010: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 319
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 237
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 26
Total of all active and inactive participants 2010-01-01 263
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
Total participants 2010-01-01 263
Number of participants with account balances 2010-01-01 100
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 0
2009: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 327
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 295
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 22
Total of all active and inactive participants 2009-01-01 317
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 317
Number of participants with account balances 2009-01-01 113
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2010: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	319
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	237
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	26
Total of all active and inactive participants	2010-01-01	263
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	263
Number of participants with account balances	2010-01-01	100
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	0
2009: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	327
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	295
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	22
Total of all active and inactive participants	2009-01-01	317
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	317
Number of participants with account balances	2009-01-01	113
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN

Measure	Date	Value
2010 : BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2010 401k financial data
Total unrealized appreciation/depreciation of assets	2010-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$0
Total income from all sources (including contributions)	2010-12-31	$83,120
Total loss/gain on sale of assets	2010-12-31	$0
Total of all expenses incurred	2010-12-31	$78,931
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$78,931
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$0
Value of total assets at end of year	2010-12-31	$800,184
Value of total assets at beginning of year	2010-12-31	$795,995
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$0
Total interest from all sources	2010-12-31	$10,069
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2010-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Value of net income/loss	2010-12-31	$4,189
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$800,184
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$795,995
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2010-12-31	$555,842
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2010-12-31	$522,775
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2010-12-31	$10,069
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$244,342
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$273,220
Expenses. Payments to insurance carriers foe the provision of benefits	2010-12-31	$5,491
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2010-12-31	$73,051
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2010-12-31	No
Was there a failure to transmit to the plan any participant contributions	2010-12-31	No
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$73,440
Did the plan have assets held for investment	2010-12-31	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	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2010-12-31	Disclaimer
Accountancy firm name	2010-12-31	ARNETT & FOSTER P.L.L.C.
Accountancy firm EIN	2010-12-31	550486667
2009 : BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2009 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2009-12-31	$0

Form 5500 Responses for BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN

2010: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes
2008: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2008 form 5500 responses
2008-01-01	Type of plan entity	Single employer plan
2008-01-01	Submission has been amended	No
2008-01-01	This submission is the final filing	No
2008-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2008-01-01	Plan is a collectively bargained plan	No
2007: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2007 form 5500 responses
2007-01-01	Type of plan entity	Single employer plan
2007-01-01	Submission has been amended	No
2007-01-01	This submission is the final filing	No
2007-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2007-01-01	Plan is a collectively bargained plan	No
2006: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2006 form 5500 responses
2006-01-01	Type of plan entity	Single employer plan
2006-01-01	Submission has been amended	No
2006-01-01	This submission is the final filing	No
2006-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2006-01-01	Plan is a collectively bargained plan	No
2005: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2005 form 5500 responses
2005-01-01	Type of plan entity	Single employer plan
2005-01-01	Submission has been amended	No
2005-01-01	This submission is the final filing	No
2005-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2005-01-01	Plan is a collectively bargained plan	No
2004: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2004 form 5500 responses
2004-01-01	Type of plan entity	Single employer plan
2004-01-01	Submission has been amended	No
2004-01-01	This submission is the final filing	No
2004-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2004-01-01	Plan is a collectively bargained plan	No
2003: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2003 form 5500 responses
2003-01-01	Type of plan entity	Single employer plan
2003-01-01	Submission has been amended	No
2003-01-01	This submission is the final filing	No
2003-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2003-01-01	Plan is a collectively bargained plan	No
2002: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2002 form 5500 responses
2002-01-01	Type of plan entity	Single employer plan
2002-01-01	Submission has been amended	No
2002-01-01	This submission is the final filing	No
2002-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2002-01-01	Plan is a collectively bargained plan	No
2001: BUCYRUS COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2001 form 5500 responses
2001-02-01	Type of plan entity	Single employer plan
2001-02-01	First time form 5500 has been submitted	Yes
2001-02-01	Submission has been amended	No
2001-02-01	This submission is the final filing	No
2001-02-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2001-02-01	Plan is a collectively bargained plan	No

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Company Name:	BUCYRUS COMMUNITY HOSPITAL INC.
Employer identification number (EIN):	344468311
NAIC Classification:	622000
NAIC Description:	Hospitals