401k Plan data: ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN plan

ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN 401k Plan overview

Plan Name	ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN
Plan identification number	001

ATHENS REHABILITATION & SENIOR CARE 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.

401k Sponsoring company profile

ATHENS REHABILITATION & SENIOR CARE has sponsored the creation of one or more 401k plans.

Company Name: ATHENS REHABILITATION & SENIOR CARE

Employer identification number (EIN): 452318609

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2016-01-01 FRED PEPPER 2017-07-31 FRED PEPPER 2017-07-28
001 2015-01-01 FRED PEPPER 2016-09-23 FRED PEPPER 2016-09-23
001 2014-01-01 SARA WALLACE 2015-06-18 SARA WALLACE 2015-06-18
001 2013-01-01 SARA WALLACE 2014-08-21 SARA WALLACE 2014-08-21
001 2012-01-01 SARA WALLACE
001 2011-01-01 SARA WALLACE

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2016-01-01	FRED PEPPER	2017-07-31	FRED PEPPER	2017-07-28
001	2015-01-01	FRED PEPPER	2016-09-23	FRED PEPPER	2016-09-23
001	2014-01-01	SARA WALLACE	2015-06-18	SARA WALLACE	2015-06-18
001	2013-01-01	SARA WALLACE	2014-08-21	SARA WALLACE	2014-08-21
001	2012-01-01	SARA WALLACE
001	2011-01-01	SARA WALLACE

Plan Statistics for ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN

401k plan membership statisitcs for ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN

Measure Date Value
2012: ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 17
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 16
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 16
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 16
Number of participants with account balances 2012-01-01 15
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 17
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 17
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 17
Number of participants with account balances 2011-01-01 17
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0

Measure	Date	Value
2012: ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	17
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	16
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	16
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	16
Number of participants with account balances	2012-01-01	15
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	17
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	17
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	17
Number of participants with account balances	2011-01-01	17
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0

Financial Data on ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN

Measure	Date	Value
2012 : ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN 2012 401k financial data
Total income from all sources	2012-12-31	$69,823
Expenses. Total of all expenses incurred	2012-12-31	$77,584
Benefits paid (including direct rollovers)	2012-12-31	$75,747
Total plan assets at end of year	2012-12-31	$296,011
Total plan assets at beginning of year	2012-12-31	$303,772
Value of fidelity bond covering the plan	2012-12-31	$50,000
Total contributions received or receivable from participants	2012-12-31	$23,411
Other income received	2012-12-31	$30,925
Net income (gross income less expenses)	2012-12-31	$-7,761
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$296,011
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$303,772
Total contributions received or receivable from employer(s)	2012-12-31	$15,487
Expenses. Administrative service providers (salaries,fees and commissions)	2012-12-31	$1,837
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
2011 : ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN 2011 401k financial data
Total income from all sources	2011-12-31	$303,774
Expenses. Total of all expenses incurred	2011-12-31	$2
Total plan assets at end of year	2011-12-31	$303,772
Total plan assets at beginning of year	2011-12-31	$0
Value of fidelity bond covering the plan	2011-12-31	$50,000
Total contributions received or receivable from participants	2011-12-31	$5,986
Contributions received from other sources (not participants or employers)	2011-12-31	$295,081
Other income received	2011-12-31	$-105
Net income (gross income less expenses)	2011-12-31	$303,772
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$303,772
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$0
Total contributions received or receivable from employer(s)	2011-12-31	$2,812
Expenses. Administrative service providers (salaries,fees and commissions)	2011-12-31	$2
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2011-12-31	$0

Form 5500 Responses for ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN

2012: ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: ATHENS REHABILITATION & SENIOR CARE 401(K) PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	First time form 5500 has been submitted	Yes
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

102663

Policy instance

Insurance contract or identification number	102663
Number of Individuals Covered	16
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,557
Commission paid to Insurance Broker	USD $1,557
Insurance broker name	NBC SECURITIES INC

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

102663

Policy instance

Insurance contract or identification number	102663
Number of Individuals Covered	17
Insurance policy start date	2011-08-01
Insurance policy end date	2011-12-31

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Company Name:	ATHENS REHABILITATION & SENIOR CARE
Employer identification number (EIN):	452318609
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities