401k Plan data: DESIGNER BLINDS HEALTH PLAN plan

DESIGNER BLINDS HEALTH PLAN 401k Plan overview

Plan Name	DESIGNER BLINDS HEALTH PLAN
Plan identification number	503

DESIGNER BLINDS HEALTH PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

DESIGNER BLINDS OF OMAHA, INC. has sponsored the creation of one or more 401k plans.

Company Name: DESIGNER BLINDS OF OMAHA, INC.

Employer identification number (EIN): 470732639

NAIC Classification: 442291
NAIC Description: Window Treatment Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DESIGNER BLINDS HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2012-01-01 STEVE WOODWORTH
503 2011-01-01 DIANE MACH DIANE MACH 2012-07-03
503 2009-01-01 DIANE MACH DIANE MACH 2010-06-23

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
503	2012-01-01	STEVE WOODWORTH
503	2011-01-01	DIANE MACH	DIANE MACH	2012-07-03
503	2009-01-01	DIANE MACH	DIANE MACH	2010-06-23

Plan Statistics for DESIGNER BLINDS HEALTH PLAN

401k plan membership statisitcs for DESIGNER BLINDS HEALTH PLAN

Measure Date Value
2012: DESIGNER BLINDS HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 84
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 0
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 0
2011: DESIGNER BLINDS HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 79
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 84
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 84
2009: DESIGNER BLINDS HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 91
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 79
Number of retired or separated participants receiving benefits 2009-01-01 2
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 81

Measure	Date	Value
2012: DESIGNER BLINDS HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	84
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	0
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	0
2011: DESIGNER BLINDS HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	79
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	84
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	84
2009: DESIGNER BLINDS HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	91
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	79
Number of retired or separated participants receiving benefits	2009-01-01	2
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	81

Form 5500 Responses for DESIGNER BLINDS HEALTH PLAN

2012: DESIGNER BLINDS HEALTH 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	Yes
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 benefit arrangement – Insurance	Yes
2011: DESIGNER BLINDS HEALTH PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
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 benefit arrangement – Insurance	Yes
2009: DESIGNER BLINDS HEALTH PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

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Company Name:	DESIGNER BLINDS OF OMAHA, INC.
Employer identification number (EIN):	470732639
NAIC Classification:	442291
NAIC Description:	Window Treatment Stores