401k Plan data: FOSBER AMERICA SAVINGS & RETIREMENT PLAN plan

FOSBER AMERICA SAVINGS & RETIREMENT PLAN 401k Plan overview

Plan Name	FOSBER AMERICA SAVINGS & RETIREMENT PLAN
Plan identification number	001

FOSBER AMERICA SAVINGS & RETIREMENT PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Age/Service Weighted or new comparability or similar plan - Age/Service Weighted Plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the theshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of section 401(l).
Profit-sharing
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.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

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

Company Name: FOSBER AMERICA, INC.

Employer identification number (EIN): 391714500

NAIC Classification: 423800

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FOSBER AMERICA SAVINGS & RETIREMENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-07-01
001 2021-07-01
001 2020-07-01
001 2019-07-01
001 2018-07-01
001 2017-07-01 JEANNE RAHR
001 2016-07-01 JEANNE RAHR
001 2015-07-01 JEANNE RAHR 2016-10-21
001 2014-07-01 JEANNE RAHR 2015-09-04
001 2013-07-01 JEANNE RAHR 2014-09-29
001 2012-07-01 JEANNE RAHR 2013-09-27
001 2011-07-01 JEANNE RAHR 2012-11-28
001 2010-07-01 JEANNE RAHR 2012-04-05 JEANNE RAHR 2012-04-05

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2022-07-01
001	2021-07-01
001	2020-07-01
001	2019-07-01
001	2018-07-01
001	2017-07-01	JEANNE RAHR
001	2016-07-01	JEANNE RAHR
001	2015-07-01	JEANNE RAHR	2016-10-21
001	2014-07-01	JEANNE RAHR	2015-09-04
001	2013-07-01	JEANNE RAHR	2014-09-29
001	2012-07-01	JEANNE RAHR	2013-09-27
001	2011-07-01	JEANNE RAHR	2012-11-28
001	2010-07-01	JEANNE RAHR	2012-04-05	JEANNE RAHR	2012-04-05

Plan Statistics for FOSBER AMERICA SAVINGS & RETIREMENT PLAN

401k plan membership statisitcs for FOSBER AMERICA SAVINGS & RETIREMENT PLAN

Measure Date Value
2022: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-07-01 199
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 181
Number of retired or separated participants receiving benefits 2022-07-01 0
Number of other retired or separated participants entitled to future benefits 2022-07-01 27
Total of all active and inactive participants 2022-07-01 208
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-07-01 0
Total participants 2022-07-01 208
Number of participants with account balances 2022-07-01 184
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-07-01 5
2021: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 173
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 153
Number of other retired or separated participants entitled to future benefits 2021-07-01 35
Total of all active and inactive participants 2021-07-01 188
Total participants 2021-07-01 188
Number of participants with account balances 2021-07-01 175
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-07-01 14
2020: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 172
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 138
Number of retired or separated participants receiving benefits 2020-07-01 1
Number of other retired or separated participants entitled to future benefits 2020-07-01 25
Total of all active and inactive participants 2020-07-01 164
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-07-01 0
Total participants 2020-07-01 164
Number of participants with account balances 2020-07-01 156
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-07-01 9
2019: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 166
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 142
Number of retired or separated participants receiving benefits 2019-07-01 0
Number of other retired or separated participants entitled to future benefits 2019-07-01 24
Total of all active and inactive participants 2019-07-01 166
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-07-01 0
Total participants 2019-07-01 166
Number of participants with account balances 2019-07-01 154
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-07-01 11
2018: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 155
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 135
Number of retired or separated participants receiving benefits 2018-07-01 2
Number of other retired or separated participants entitled to future benefits 2018-07-01 20
Total of all active and inactive participants 2018-07-01 157
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-07-01 0
Total participants 2018-07-01 157
Number of participants with account balances 2018-07-01 147
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-07-01 6
2017: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 136
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 121
Number of retired or separated participants receiving benefits 2017-07-01 2
Number of other retired or separated participants entitled to future benefits 2017-07-01 25
Total of all active and inactive participants 2017-07-01 148
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-07-01 0
Total participants 2017-07-01 148
Number of participants with account balances 2017-07-01 141
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-07-01 9
2016: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 127
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 111
Number of retired or separated participants receiving benefits 2016-07-01 1
Number of other retired or separated participants entitled to future benefits 2016-07-01 20
Total of all active and inactive participants 2016-07-01 132
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-07-01 0
Total participants 2016-07-01 132
Number of participants with account balances 2016-07-01 124
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-07-01 8

Measure	Date	Value
2022: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	199
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	181
Number of retired or separated participants receiving benefits	2022-07-01	0
Number of other retired or separated participants entitled to future benefits	2022-07-01	27
Total of all active and inactive participants	2022-07-01	208
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-07-01	0
Total participants	2022-07-01	208
Number of participants with account balances	2022-07-01	184
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-07-01	5
2021: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	173
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	153
Number of other retired or separated participants entitled to future benefits	2021-07-01	35
Total of all active and inactive participants	2021-07-01	188
Total participants	2021-07-01	188
Number of participants with account balances	2021-07-01	175
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-07-01	14
2020: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	172
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	138
Number of retired or separated participants receiving benefits	2020-07-01	1
Number of other retired or separated participants entitled to future benefits	2020-07-01	25
Total of all active and inactive participants	2020-07-01	164
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-07-01	0
Total participants	2020-07-01	164
Number of participants with account balances	2020-07-01	156
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-07-01	9
2019: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	166
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	142
Number of retired or separated participants receiving benefits	2019-07-01	0
Number of other retired or separated participants entitled to future benefits	2019-07-01	24
Total of all active and inactive participants	2019-07-01	166
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-07-01	0
Total participants	2019-07-01	166
Number of participants with account balances	2019-07-01	154
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-07-01	11
2018: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	155
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	135
Number of retired or separated participants receiving benefits	2018-07-01	2
Number of other retired or separated participants entitled to future benefits	2018-07-01	20
Total of all active and inactive participants	2018-07-01	157
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-07-01	0
Total participants	2018-07-01	157
Number of participants with account balances	2018-07-01	147
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-07-01	6
2017: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	136
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	121
Number of retired or separated participants receiving benefits	2017-07-01	2
Number of other retired or separated participants entitled to future benefits	2017-07-01	25
Total of all active and inactive participants	2017-07-01	148
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-07-01	0
Total participants	2017-07-01	148
Number of participants with account balances	2017-07-01	141
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-07-01	9
2016: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	127
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	111
Number of retired or separated participants receiving benefits	2016-07-01	1
Number of other retired or separated participants entitled to future benefits	2016-07-01	20
Total of all active and inactive participants	2016-07-01	132
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-07-01	0
Total participants	2016-07-01	132
Number of participants with account balances	2016-07-01	124
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-07-01	8

Financial Data on FOSBER AMERICA SAVINGS & RETIREMENT PLAN

Measure	Date	Value
2023 : FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2023 401k financial data
Total income from all sources (including contributions)	2023-06-30	$4,961,979
Total of all expenses incurred	2023-06-30	$2,884,223
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2023-06-30	$2,850,166
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2023-06-30	$1,824,349
Value of total assets at end of year	2023-06-30	$25,637,255
Value of total assets at beginning of year	2023-06-30	$23,559,499
Total of administrative expenses incurred including professional, contract, advisory and management fees	2023-06-30	$34,057
Total interest from all sources	2023-06-30	$22,039
Total dividends received (eg from common stock, registered investment company shares)	2023-06-30	$490,850
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2023-06-30	No
Total dividends received from registered investment company shares (eg mutual funds)	2023-06-30	$490,850
Was this plan covered by a fidelity bond	2023-06-30	Yes
Value of fidelity bond cover	2023-06-30	$500,000
If this is an individual account plan, was there a blackout period	2023-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2023-06-30	No
Contributions received from participants	2023-06-30	$1,317,567
Participant contributions at end of year	2023-06-30	$383,670
Participant contributions at beginning of year	2023-06-30	$286,744
Participant contributions at beginning of year	2023-06-30	$36
Income. Received or receivable in cash from other sources (including rollovers)	2023-06-30	$16,386
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2023-06-30	No
Income. Non cash contributions	2023-06-30	$0
Value of net income/loss	2023-06-30	$2,077,756
Value of net assets at end of year (total assets less liabilities)	2023-06-30	$25,637,255
Value of net assets at beginning of year (total assets less liabilities)	2023-06-30	$23,559,499
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2023-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2023-06-30	No
Were any leases to which the plan was party in default or uncollectible	2023-06-30	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2023-06-30	$25,250,902
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2023-06-30	$23,231,640
Interest on participant loans	2023-06-30	$21,090
Interest earned on other investments	2023-06-30	$949
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2023-06-30	$2,683
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2023-06-30	$41,079
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2023-06-30	$2,624,741
Net investment gain or loss from common/collective trusts	2023-06-30	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2023-06-30	No
Was there a failure to transmit to the plan any participant contributions	2023-06-30	No
Has the plan failed to provide any benefit when due under the plan	2023-06-30	No
Contributions received in cash from employer	2023-06-30	$490,396
Employer contributions (assets) at beginning of year	2023-06-30	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2023-06-30	$2,850,166
Contract administrator fees	2023-06-30	$34,057
Did the plan have assets held for investment	2023-06-30	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2023-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2023-06-30	No
Opinion of an independent qualified public accountant for this plan	2023-06-30	Unqualified
Accountancy firm name	2023-06-30	HAWKINS ASH CPAS, LLP
Accountancy firm EIN	2023-06-30	390912608
2022 : FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2022 401k financial data
Total income from all sources (including contributions)	2022-06-30	$-2,723,375
Total of all expenses incurred	2022-06-30	$889,011
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-06-30	$850,820
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-06-30	$1,719,765
Value of total assets at end of year	2022-06-30	$23,559,499
Value of total assets at beginning of year	2022-06-30	$27,171,885
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-06-30	$38,191
Total interest from all sources	2022-06-30	$15,554
Total dividends received (eg from common stock, registered investment company shares)	2022-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-06-30	No
Was this plan covered by a fidelity bond	2022-06-30	Yes
Value of fidelity bond cover	2022-06-30	$500,000
If this is an individual account plan, was there a blackout period	2022-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2022-06-30	No
Contributions received from participants	2022-06-30	$1,237,650
Participant contributions at end of year	2022-06-30	$286,744
Participant contributions at beginning of year	2022-06-30	$257,212
Participant contributions at end of year	2022-06-30	$36
Income. Received or receivable in cash from other sources (including rollovers)	2022-06-30	$42,550
Administrative expenses (other) incurred	2022-06-30	$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	2022-06-30	No
Value of net income/loss	2022-06-30	$-3,612,386
Value of net assets at end of year (total assets less liabilities)	2022-06-30	$23,559,499
Value of net assets at beginning of year (total assets less liabilities)	2022-06-30	$27,171,885
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-06-30	No
Were any leases to which the plan was party in default or uncollectible	2022-06-30	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-06-30	$23,231,640
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-06-30	$26,874,326
Interest on participant loans	2022-06-30	$15,554
Income. Interest from loans (other than to participants)	2022-06-30	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2022-06-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-06-30	$41,079
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-06-30	$40,347
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-06-30	$-4,458,694
Net investment gain or loss from common/collective trusts	2022-06-30	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-06-30	No
Was there a failure to transmit to the plan any participant contributions	2022-06-30	No
Has the plan failed to provide any benefit when due under the plan	2022-06-30	No
Contributions received in cash from employer	2022-06-30	$439,565
Employer contributions (assets) at end of year	2022-06-30	$0
Income. Dividends from preferred stock	2022-06-30	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-06-30	$850,820
Contract administrator fees	2022-06-30	$38,191
Did the plan have assets held for investment	2022-06-30	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	2022-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-06-30	No
Opinion of an independent qualified public accountant for this plan	2022-06-30	Unqualified
Accountancy firm name	2022-06-30	HAWKINS ASH CPAS, LLP
Accountancy firm EIN	2022-06-30	390912608
2021 : FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-06-30	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-06-30	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-06-30	$0
Total income from all sources (including contributions)	2021-06-30	$8,260,303
Total loss/gain on sale of assets	2021-06-30	$0
Total of all expenses incurred	2021-06-30	$1,880,121
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-06-30	$1,849,223
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-06-30	$1,570,226
Value of total assets at end of year	2021-06-30	$27,171,885
Value of total assets at beginning of year	2021-06-30	$20,791,703
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-06-30	$30,898
Total interest from all sources	2021-06-30	$16,400
Total dividends received (eg from common stock, registered investment company shares)	2021-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-06-30	No
Was this plan covered by a fidelity bond	2021-06-30	Yes
Value of fidelity bond cover	2021-06-30	$500,000
If this is an individual account plan, was there a blackout period	2021-06-30	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-06-30	$0
Were there any nonexempt tranactions with any party-in-interest	2021-06-30	No
Contributions received from participants	2021-06-30	$1,091,702
Participant contributions at end of year	2021-06-30	$257,212
Participant contributions at beginning of year	2021-06-30	$324,098
Income. Received or receivable in cash from other sources (including rollovers)	2021-06-30	$70,612
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-06-30	No
Value of net income/loss	2021-06-30	$6,380,182
Value of net assets at end of year (total assets less liabilities)	2021-06-30	$27,171,885
Value of net assets at beginning of year (total assets less liabilities)	2021-06-30	$20,791,703
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-06-30	No
Were any leases to which the plan was party in default or uncollectible	2021-06-30	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-06-30	$26,874,326
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-06-30	$20,264,739
Interest on participant loans	2021-06-30	$16,400
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-06-30	$40,347
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-06-30	$202,866
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-06-30	$6,673,677
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-06-30	No
Was there a failure to transmit to the plan any participant contributions	2021-06-30	No
Has the plan failed to provide any benefit when due under the plan	2021-06-30	No
Contributions received in cash from employer	2021-06-30	$407,912
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-06-30	$1,849,223
Contract administrator fees	2021-06-30	$30,898
Did the plan have assets held for investment	2021-06-30	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	2021-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-06-30	No
Opinion of an independent qualified public accountant for this plan	2021-06-30	Disclaimer
Accountancy firm name	2021-06-30	HAWKINS ASH CPAS, LLP
Accountancy firm EIN	2021-06-30	390912608
2020 : FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-06-30	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-06-30	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-06-30	$0
Total income from all sources (including contributions)	2020-06-30	$2,404,529
Total loss/gain on sale of assets	2020-06-30	$0
Total of all expenses incurred	2020-06-30	$383,766
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-06-30	$357,117
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-06-30	$1,502,721
Value of total assets at end of year	2020-06-30	$20,791,703
Value of total assets at beginning of year	2020-06-30	$18,770,940
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-06-30	$26,649
Total interest from all sources	2020-06-30	$15,993
Total dividends received (eg from common stock, registered investment company shares)	2020-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-06-30	No
Was this plan covered by a fidelity bond	2020-06-30	Yes
Value of fidelity bond cover	2020-06-30	$500,000
If this is an individual account plan, was there a blackout period	2020-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2020-06-30	No
Contributions received from participants	2020-06-30	$1,054,110
Participant contributions at end of year	2020-06-30	$324,098
Participant contributions at beginning of year	2020-06-30	$242,205
Participant contributions at end of year	2020-06-30	$0
Participant contributions at beginning of year	2020-06-30	$42,502
Income. Received or receivable in cash from other sources (including rollovers)	2020-06-30	$55,652
Value of other receiveables (less allowance for doubtful accounts) at end of year	2020-06-30	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2020-06-30	$654
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-06-30	No
Income. Non cash contributions	2020-06-30	$0
Value of net income/loss	2020-06-30	$2,020,763
Value of net assets at end of year (total assets less liabilities)	2020-06-30	$20,791,703
Value of net assets at beginning of year (total assets less liabilities)	2020-06-30	$18,770,940
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-06-30	No
Were any leases to which the plan was party in default or uncollectible	2020-06-30	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-06-30	$20,264,739
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-06-30	$18,263,964
Interest on participant loans	2020-06-30	$15,021
Interest earned on other investments	2020-06-30	$972
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-06-30	$202,866
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-06-30	$205,897
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-06-30	$885,815
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-06-30	No
Was there a failure to transmit to the plan any participant contributions	2020-06-30	No
Has the plan failed to provide any benefit when due under the plan	2020-06-30	No
Contributions received in cash from employer	2020-06-30	$392,959
Employer contributions (assets) at end of year	2020-06-30	$0
Employer contributions (assets) at beginning of year	2020-06-30	$15,718
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-06-30	$357,117
Contract administrator fees	2020-06-30	$26,649
Did the plan have assets held for investment	2020-06-30	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	2020-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-06-30	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2020-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2020-06-30	Disclaimer
Accountancy firm name	2020-06-30	HERMANS & ASSOCIATES, CPA'S, S.C.
Accountancy firm EIN	2020-06-30	391421794
2019 : FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-06-30	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-06-30	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-06-30	$0
Total income from all sources (including contributions)	2019-06-30	$2,485,659
Total loss/gain on sale of assets	2019-06-30	$0
Total of all expenses incurred	2019-06-30	$228,458
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-06-30	$205,555
Value of total corrective distributions	2019-06-30	$894
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-06-30	$1,473,582
Value of total assets at end of year	2019-06-30	$18,770,940
Value of total assets at beginning of year	2019-06-30	$16,513,739
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-06-30	$22,009
Total interest from all sources	2019-06-30	$18,552
Total dividends received (eg from common stock, registered investment company shares)	2019-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-06-30	No
Was this plan covered by a fidelity bond	2019-06-30	Yes
Value of fidelity bond cover	2019-06-30	$500,000
If this is an individual account plan, was there a blackout period	2019-06-30	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-06-30	$0
Were there any nonexempt tranactions with any party-in-interest	2019-06-30	No
Contributions received from participants	2019-06-30	$985,971
Participant contributions at end of year	2019-06-30	$242,205
Participant contributions at beginning of year	2019-06-30	$245,144
Participant contributions at end of year	2019-06-30	$42,502
Participant contributions at beginning of year	2019-06-30	$33,509
Income. Received or receivable in cash from other sources (including rollovers)	2019-06-30	$128,648
Value of other receiveables (less allowance for doubtful accounts) at end of year	2019-06-30	$654
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2019-06-30	$537
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-06-30	No
Value of net income/loss	2019-06-30	$2,257,201
Value of net assets at end of year (total assets less liabilities)	2019-06-30	$18,770,940
Value of net assets at beginning of year (total assets less liabilities)	2019-06-30	$16,513,739
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-06-30	No
Were any leases to which the plan was party in default or uncollectible	2019-06-30	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-06-30	$18,263,964
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-06-30	$16,019,970
Interest on participant loans	2019-06-30	$15,279
Interest earned on other investments	2019-06-30	$3,273
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-06-30	$205,897
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-06-30	$201,944
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-06-30	$993,525
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-06-30	No
Was there a failure to transmit to the plan any participant contributions	2019-06-30	No
Has the plan failed to provide any benefit when due under the plan	2019-06-30	No
Contributions received in cash from employer	2019-06-30	$358,963
Employer contributions (assets) at end of year	2019-06-30	$15,718
Employer contributions (assets) at beginning of year	2019-06-30	$12,635
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-06-30	$205,555
Contract administrator fees	2019-06-30	$22,009
Did the plan have assets held for investment	2019-06-30	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	2019-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-06-30	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2019-06-30	Disclaimer
Accountancy firm name	2019-06-30	HERMANS & ASSOCIATES, CPA'S, S.C.
Accountancy firm EIN	2019-06-30	391421794
2018 : FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-06-30	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-06-30	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-06-30	$0
Total income from all sources (including contributions)	2018-06-30	$2,762,705
Total loss/gain on sale of assets	2018-06-30	$0
Total of all expenses incurred	2018-06-30	$123,951
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-06-30	$94,705
Value of total corrective distributions	2018-06-30	$14,675
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-06-30	$1,205,444
Value of total assets at end of year	2018-06-30	$16,513,739
Value of total assets at beginning of year	2018-06-30	$13,874,985
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-06-30	$14,571
Total interest from all sources	2018-06-30	$16,344
Total dividends received (eg from common stock, registered investment company shares)	2018-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-06-30	No
Was this plan covered by a fidelity bond	2018-06-30	Yes
Value of fidelity bond cover	2018-06-30	$500,000
If this is an individual account plan, was there a blackout period	2018-06-30	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-06-30	$0
Were there any nonexempt tranactions with any party-in-interest	2018-06-30	No
Contributions received from participants	2018-06-30	$823,345
Participant contributions at end of year	2018-06-30	$245,144
Participant contributions at beginning of year	2018-06-30	$268,077
Participant contributions at end of year	2018-06-30	$33,509
Participant contributions at beginning of year	2018-06-30	$0
Income. Received or receivable in cash from other sources (including rollovers)	2018-06-30	$83,424
Value of other receiveables (less allowance for doubtful accounts) at end of year	2018-06-30	$537
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2018-06-30	$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	2018-06-30	No
Value of net income/loss	2018-06-30	$2,638,754
Value of net assets at end of year (total assets less liabilities)	2018-06-30	$16,513,739
Value of net assets at beginning of year (total assets less liabilities)	2018-06-30	$13,874,985
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-06-30	No
Were any leases to which the plan was party in default or uncollectible	2018-06-30	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2018-06-30	$16,019,970
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2018-06-30	$13,407,116
Interest on participant loans	2018-06-30	$14,844
Interest earned on other investments	2018-06-30	$1,500
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2018-06-30	$201,944
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2018-06-30	$199,792
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-06-30	$1,540,917
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-06-30	No
Was there a failure to transmit to the plan any participant contributions	2018-06-30	No
Has the plan failed to provide any benefit when due under the plan	2018-06-30	No
Contributions received in cash from employer	2018-06-30	$298,675
Employer contributions (assets) at end of year	2018-06-30	$12,635
Employer contributions (assets) at beginning of year	2018-06-30	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-06-30	$94,705
Contract administrator fees	2018-06-30	$14,571
Did the plan have assets held for investment	2018-06-30	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	2018-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-06-30	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2018-06-30	Disclaimer
Accountancy firm name	2018-06-30	HERMANS & ASSOCIATES, CPA'S, S.C.
Accountancy firm EIN	2018-06-30	391421794
2017 : FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2017 401k financial data
Total unrealized appreciation/depreciation of assets	2017-06-30	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-06-30	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-06-30	$0
Total income from all sources (including contributions)	2017-06-30	$2,794,895
Total loss/gain on sale of assets	2017-06-30	$0
Total of all expenses incurred	2017-06-30	$287,521
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-06-30	$277,208
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-06-30	$987,261
Value of total assets at end of year	2017-06-30	$13,874,985
Value of total assets at beginning of year	2017-06-30	$11,367,611
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-06-30	$10,313
Total interest from all sources	2017-06-30	$13,759
Total dividends received (eg from common stock, registered investment company shares)	2017-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-06-30	No
Was this plan covered by a fidelity bond	2017-06-30	Yes
Value of fidelity bond cover	2017-06-30	$500,000
If this is an individual account plan, was there a blackout period	2017-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2017-06-30	No
Contributions received from participants	2017-06-30	$711,215
Participant contributions at end of year	2017-06-30	$268,077
Participant contributions at beginning of year	2017-06-30	$211,462
Participant contributions at end of year	2017-06-30	$0
Participant contributions at beginning of year	2017-06-30	$24,436
Value of other receiveables (less allowance for doubtful accounts) at end of year	2017-06-30	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2017-06-30	$2,136
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-06-30	No
Value of net income/loss	2017-06-30	$2,507,374
Value of net assets at end of year (total assets less liabilities)	2017-06-30	$13,874,985
Value of net assets at beginning of year (total assets less liabilities)	2017-06-30	$11,367,611
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-06-30	No
Were any leases to which the plan was party in default or uncollectible	2017-06-30	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2017-06-30	$13,407,116
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2017-06-30	$10,918,285
Interest on participant loans	2017-06-30	$13,315
Interest earned on other investments	2017-06-30	$444
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2017-06-30	$199,792
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2017-06-30	$198,731
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2017-06-30	$1,793,875
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-06-30	No
Was there a failure to transmit to the plan any participant contributions	2017-06-30	No
Has the plan failed to provide any benefit when due under the plan	2017-06-30	No
Contributions received in cash from employer	2017-06-30	$276,046
Employer contributions (assets) at end of year	2017-06-30	$0
Employer contributions (assets) at beginning of year	2017-06-30	$12,561
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-06-30	$277,208
Contract administrator fees	2017-06-30	$10,313
Did the plan have assets held for investment	2017-06-30	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	2017-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-06-30	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2017-06-30	Disclaimer
Accountancy firm name	2017-06-30	HERMANS & ASSOCIATES, CPS'S, S.C.
Accountancy firm EIN	2017-06-30	391421794

Form 5500 Responses for FOSBER AMERICA SAVINGS & RETIREMENT PLAN

2022: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Submission has been amended	No
2022-07-01	This submission is the final filing	No
2022-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-07-01	Plan is a collectively bargained plan	No
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – Trust	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement - Trust	Yes
2021: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Mulitple employer plan
2021-07-01	Submission has been amended	No
2021-07-01	This submission is the final filing	No
2021-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-07-01	Plan is a collectively bargained plan	No
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – Trust	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement - Trust	Yes
2020: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Mulitple employer plan
2020-07-01	Submission has been amended	No
2020-07-01	This submission is the final filing	No
2020-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-07-01	Plan is a collectively bargained plan	No
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan funding arrangement – Trust	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement - Trust	Yes
2019: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Mulitple employer plan
2019-07-01	Submission has been amended	No
2019-07-01	This submission is the final filing	No
2019-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-07-01	Plan is a collectively bargained plan	No
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan funding arrangement – Trust	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement - Trust	Yes
2018: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Mulitple employer plan
2018-07-01	Submission has been amended	No
2018-07-01	This submission is the final filing	No
2018-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-07-01	Plan is a collectively bargained plan	No
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan funding arrangement – Trust	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement - Trust	Yes
2017: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Mulitple employer plan
2017-07-01	Submission has been amended	No
2017-07-01	This submission is the final filing	No
2017-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-07-01	Plan is a collectively bargained plan	No
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan funding arrangement – Trust	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement - Trust	Yes
2016: FOSBER AMERICA SAVINGS & RETIREMENT PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Mulitple employer plan
2016-07-01	Submission has been amended	No
2016-07-01	This submission is the final filing	No
2016-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-07-01	Plan is a collectively bargained plan	No
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan funding arrangement – Trust	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2016-07-01	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-B0-HD4Z

Policy instance

Insurance contract or identification number	GAP-B0-HD4Z
Number of Individuals Covered	208
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $94
Total amount of fees paid to insurance company	USD $0
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
Commission paid to Insurance Broker	USD $94
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

GAP-B0-HD4Z

Policy instance

Insurance contract or identification number	GAP-B0-HD4Z
Number of Individuals Covered	186
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $103
Total amount of fees paid to insurance company	USD $0
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
Commission paid to Insurance Broker	USD $103
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

GAP-B0-HD4Z

Policy instance

Insurance contract or identification number	GAP-B0-HD4Z
Number of Individuals Covered	164
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $331
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	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
Commission paid to Insurance Broker	USD $331
Insurance broker organization code?	3

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

Policy contract number

GAP-B0-HD4Z

Policy instance

Insurance contract or identification number	GAP-B0-HD4Z
Number of Individuals Covered	142
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $534
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	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
Commission paid to Insurance Broker	USD $534
Insurance broker organization code?	3

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

Policy contract number

GAP-B0-HD4Z

Policy instance

Insurance contract or identification number	GAP-B0-HD4Z
Number of Individuals Covered	157
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $589
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	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
Commission paid to Insurance Broker	USD $589
Insurance broker organization code?	3

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

Policy contract number

GAP-B0-HD4Z

Policy instance

Insurance contract or identification number	GAP-B0-HD4Z
Number of Individuals Covered	148
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $602
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	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
Commission paid to Insurance Broker	USD $602
Insurance broker organization code?	3
Insurance broker name	AMERIPRISE FINANCIAL SERVICES

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Company Name:	FOSBER AMERICA, INC.
Employer identification number (EIN):	391714500
NAIC Classification:	423800