401k Plan data: HIAWATHA CARE CENTER, INC. 401(K) PLAN plan

HIAWATHA CARE CENTER, INC. 401(K) PLAN 401k Plan overview

Plan Name	HIAWATHA CARE CENTER, INC. 401(K) PLAN
Plan identification number	001

HIAWATHA CARE CENTER, INC. 401(K) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

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.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

HIAWATHA CARE CENTER, INC. has sponsored the creation of one or more 401k plans.

Company Name: HIAWATHA CARE CENTER, INC.

Employer identification number (EIN): 421392023

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

Additional information about HIAWATHA CARE CENTER, INC.

Jurisdiction of Incorporation: Iowa Secretary of State Business Entities

Incorporation Date: 1992-09-08

Company Identification Number: 160636

Legal Registered Office Address: 32567 HICKORY HOLLOW LN

WAUKEE
United States of America (USA)
50263

More information about HIAWATHA CARE CENTER, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HIAWATHA CARE CENTER, INC. 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01
001 2021-01-01
001 2020-01-01
001 2019-01-01
001 2018-01-01
001 2017-01-01 KAREN CHADWICK 2018-07-17 KAREN CHADWICK 2018-07-17
001 2016-01-01 KAREN CHADWICK 2017-04-26 KAREN CHADWICK 2017-04-26
001 2015-01-01 KAREN CHADWICK 2016-07-06
001 2014-01-01 KAREN CHADWICK 2015-05-21 KAREN CHADWICK 2015-05-21
001 2013-01-01 KAREN CHADWICK 2014-05-27 KAREN CHADWICK 2014-05-27
001 2012-01-01 KAREN CHADWICK 2013-05-31 KAREN CHADWICK 2013-05-31
001 2011-01-01 KAREN CHADWICK 2012-07-26
001 2010-01-01 KENT WALTON 2011-07-26

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2022-01-01
001	2021-01-01
001	2020-01-01
001	2019-01-01
001	2018-01-01
001	2017-01-01	KAREN CHADWICK	2018-07-17	KAREN CHADWICK	2018-07-17
001	2016-01-01	KAREN CHADWICK	2017-04-26	KAREN CHADWICK	2017-04-26
001	2015-01-01	KAREN CHADWICK	2016-07-06
001	2014-01-01	KAREN CHADWICK	2015-05-21	KAREN CHADWICK	2015-05-21
001	2013-01-01	KAREN CHADWICK	2014-05-27	KAREN CHADWICK	2014-05-27
001	2012-01-01	KAREN CHADWICK	2013-05-31	KAREN CHADWICK	2013-05-31
001	2011-01-01	KAREN CHADWICK	2012-07-26
001	2010-01-01	KENT WALTON	2011-07-26

Plan Statistics for HIAWATHA CARE CENTER, INC. 401(K) PLAN

401k plan membership statisitcs for HIAWATHA CARE CENTER, INC. 401(K) PLAN

Measure Date Value
2022: HIAWATHA CARE CENTER, INC. 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 157
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 150
Number of retired or separated participants receiving benefits 2022-01-01 1
Number of other retired or separated participants entitled to future benefits 2022-01-01 12
Total of all active and inactive participants 2022-01-01 163
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 163
Number of participants with account balances 2022-01-01 48
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 0
2021: HIAWATHA CARE CENTER, INC. 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 151
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 120
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 14
Total of all active and inactive participants 2021-01-01 134
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 134
Number of participants with account balances 2021-01-01 44
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0
2020: HIAWATHA CARE CENTER, INC. 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 156
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 129
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 12
Total of all active and inactive participants 2020-01-01 141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 141
Number of participants with account balances 2020-01-01 49
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: HIAWATHA CARE CENTER, INC. 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 145
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 134
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 6
Total of all active and inactive participants 2019-01-01 140
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 140
Number of participants with account balances 2019-01-01 56
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 1
2018: HIAWATHA CARE CENTER, INC. 401(K) PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 132
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 12
Total of all active and inactive participants 2018-01-01 144
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 144
Number of participants with account balances 2018-01-01 62
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: HIAWATHA CARE CENTER, INC. 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	157
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	150
Number of retired or separated participants receiving benefits	2022-01-01	1
Number of other retired or separated participants entitled to future benefits	2022-01-01	12
Total of all active and inactive participants	2022-01-01	163
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	163
Number of participants with account balances	2022-01-01	48
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	0
2021: HIAWATHA CARE CENTER, INC. 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	151
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	120
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	14
Total of all active and inactive participants	2021-01-01	134
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	134
Number of participants with account balances	2021-01-01	44
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
2020: HIAWATHA CARE CENTER, INC. 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	156
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	129
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	12
Total of all active and inactive participants	2020-01-01	141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	141
Number of participants with account balances	2020-01-01	49
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: HIAWATHA CARE CENTER, INC. 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	145
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	134
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	6
Total of all active and inactive participants	2019-01-01	140
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	140
Number of participants with account balances	2019-01-01	56
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	1
2018: HIAWATHA CARE CENTER, INC. 401(K) PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	132
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	12
Total of all active and inactive participants	2018-01-01	144
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	144
Number of participants with account balances	2018-01-01	62
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	0

Financial Data on HIAWATHA CARE CENTER, INC. 401(K) PLAN

Measure	Date	Value
2022 : HIAWATHA CARE CENTER, INC. 401(K) 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	$0
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	$-33,245
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$28,211
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$21,750
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$116,023
Value of total assets at end of year	2022-12-31	$625,243
Value of total assets at beginning of year	2022-12-31	$686,699
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$6,461
Total interest from all sources	2022-12-31	$541
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$69,000
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	$103,623
Participant contributions at end of year	2022-12-31	$14,962
Participant contributions at beginning of year	2022-12-31	$12,270
Income. Received or receivable in cash from other sources (including rollovers)	2022-12-31	$12,356
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	$-61,456
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$625,243
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$686,699
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 pooled separate accounts at end of year	2022-12-31	$610,281
Value of interest in pooled separate accounts at beginning of year	2022-12-31	$674,429
Income. Interest from loans (other than to participants)	2022-12-31	$541
Net investment gain/loss from pooled separate accounts	2022-12-31	$-149,809
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	$44
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$21,750
Contract administrator fees	2022-12-31	$6,461
Did the plan have assets held for investment	2022-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	BERGANKDV, LTD
Accountancy firm EIN	2022-12-31	411431613
2021 : HIAWATHA CARE CENTER, INC. 401(K) 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	$168,885
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$124,761
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$118,795
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$76,789
Value of total assets at end of year	2021-12-31	$686,699
Value of total assets at beginning of year	2021-12-31	$642,575
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$5,966
Total interest from all sources	2021-12-31	$414
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$50,000
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	$76,789
Participant contributions at end of year	2021-12-31	$12,270
Participant contributions at beginning of year	2021-12-31	$13,958
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	$44,124
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$686,699
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$642,575
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 pooled separate accounts at end of year	2021-12-31	$674,429
Value of interest in pooled separate accounts at beginning of year	2021-12-31	$628,617
Income. Interest from loans (other than to participants)	2021-12-31	$414
Net investment gain/loss from pooled separate accounts	2021-12-31	$91,682
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
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$118,795
Contract administrator fees	2021-12-31	$5,966
Did the plan have assets held for investment	2021-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	BERGANKDV, LTD
Accountancy firm EIN	2021-12-31	411431613
2020 : HIAWATHA CARE CENTER, INC. 401(K) 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	$172,087
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$23,242
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$17,995
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$86,379
Value of total assets at end of year	2020-12-31	$642,575
Value of total assets at beginning of year	2020-12-31	$493,730
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$5,247
Total interest from all sources	2020-12-31	$549
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Administrative expenses professional fees incurred	2020-12-31	$5,247
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$50,000
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	$82,251
Participant contributions at end of year	2020-12-31	$13,958
Participant contributions at beginning of year	2020-12-31	$14,660
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$4,128
Other income not declared elsewhere	2020-12-31	$3
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	$148,845
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$642,575
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$493,730
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 pooled separate accounts at end of year	2020-12-31	$628,617
Value of interest in pooled separate accounts at beginning of year	2020-12-31	$478,897
Income. Interest from loans (other than to participants)	2020-12-31	$549
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-12-31	$173
Net investment gain/loss from pooled separate accounts	2020-12-31	$85,156
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
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$17,995
Did the plan have assets held for investment	2020-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Disclaimer
Accountancy firm name	2020-12-31	BERGANKDV, LTD
Accountancy firm EIN	2020-12-31	411431613
2019 : HIAWATHA CARE CENTER, INC. 401(K) 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	$158,977
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$46,743
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$41,341
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$76,947
Value of total assets at end of year	2019-12-31	$493,730
Value of total assets at beginning of year	2019-12-31	$381,496
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$5,402
Total interest from all sources	2019-12-31	$864
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Was this plan covered by a fidelity bond	2019-12-31	Yes
Value of fidelity bond cover	2019-12-31	$50,000
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	$76,947
Participant contributions at end of year	2019-12-31	$14,660
Participant contributions at beginning of year	2019-12-31	$17,736
Other income not declared elsewhere	2019-12-31	$25
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	$112,234
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$493,730
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$381,496
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
Value of interest in pooled separate accounts at end of year	2019-12-31	$478,897
Value of interest in pooled separate accounts at beginning of year	2019-12-31	$362,796
Interest on participant loans	2019-12-31	$864
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-12-31	$173
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$964
Net investment gain/loss from pooled separate accounts	2019-12-31	$81,141
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
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$41,341
Contract administrator fees	2019-12-31	$5,402
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	BERGANKDV, LTD
Accountancy firm EIN	2019-12-31	411431613
2018 : HIAWATHA CARE CENTER, INC. 401(K) PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-12-31	$0
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	$56,513
Total loss/gain on sale of assets	2018-12-31	$0
Total of all expenses incurred	2018-12-31	$20,907
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$16,518
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$77,560
Value of total assets at end of year	2018-12-31	$381,496
Value of total assets at beginning of year	2018-12-31	$345,890
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$4,389
Total interest from all sources	2018-12-31	$1,092
Total dividends received (eg from common stock, registered investment company shares)	2018-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-12-31	No
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$25,000
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	$77,560
Participant contributions at end of year	2018-12-31	$17,736
Participant contributions at beginning of year	2018-12-31	$9,766
Participant contributions at beginning of year	2018-12-31	$2,320
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2018-12-31	$74
Other income not declared elsewhere	2018-12-31	$9
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
Value of net income/loss	2018-12-31	$35,606
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$381,496
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$345,890
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
Value of interest in pooled separate accounts at end of year	2018-12-31	$362,796
Value of interest in pooled separate accounts at beginning of year	2018-12-31	$333,388
Interest on participant loans	2018-12-31	$1,092
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2018-12-31	$964
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2018-12-31	$342
Net investment gain/loss from pooled separate accounts	2018-12-31	$-22,148
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
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$16,518
Contract administrator fees	2018-12-31	$4,389
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	BERGANKDV, LTD
Accountancy firm EIN	2018-12-31	411431613

Form 5500 Responses for HIAWATHA CARE CENTER, INC. 401(K) PLAN

2022: HIAWATHA CARE CENTER, INC. 401(K) 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: HIAWATHA CARE CENTER, INC. 401(K) 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: HIAWATHA CARE CENTER, INC. 401(K) 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: HIAWATHA CARE CENTER, INC. 401(K) 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: HIAWATHA CARE CENTER, INC. 401(K) PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
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

438-00046

Policy instance

Insurance contract or identification number	438-00046
Number of Individuals Covered	0
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

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

Policy contract number

438-00046

Policy instance

Insurance contract or identification number	438-00046
Number of Individuals Covered	0
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

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

Policy contract number

438-00046

Policy instance

Insurance contract or identification number	438-00046
Number of Individuals Covered	49
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?	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

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

Policy contract number

438-00046

Policy instance

Insurance contract or identification number	438-00046
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 $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

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

Policy contract number

438-00046

Policy instance

Insurance contract or identification number	438-00046
Number of Individuals Covered	62
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 $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

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Company Name:	HIAWATHA CARE CENTER, INC.
Employer identification number (EIN):	421392023
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Jurisdiction of Incorporation:	Iowa Secretary of State Business Entities
Incorporation Date:	1992-09-08
Company Identification Number:	160636
Legal Registered Office Address:	32567 HICKORY HOLLOW LN WAUKEE United States of America (USA) 50263