401k Plan data: 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. plan

403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. 401k Plan overview

Plan Name	403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC.
Plan identification number	003

403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 403(b)(1) arrangement - See Limited Pension Plan Reporting instructions for Code section 403(b)(1) arrangements for certain exempt organizations.
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

GOODWILL INDUSTRIES OF KANSAS, INC. has sponsored the creation of one or more 401k plans.

Company Name: GOODWILL INDUSTRIES OF KANSAS, INC.

Employer identification number (EIN): 480673284

NAIC Classification: 813000
NAIC Description: Religious, Grantmaking, Civic, Professional, and Similar Organizations

Form 5500 Filing Information

Submission information for form 5500 for 401k plan 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
003 2012-01-01 GREG SANDLIN GREG SANDLIN 2013-07-31
003 2012-01-01 GREG SANDLIN GREG SANDLIN 2014-03-26
003 2011-01-01 GREG SANDLIN GREG SANDLIN 2012-10-14
003 2009-01-01 GREG SANDLIN GREG SANDLIN 2012-10-15

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
003	2012-01-01	GREG SANDLIN	GREG SANDLIN	2013-07-31
003	2012-01-01	GREG SANDLIN	GREG SANDLIN	2014-03-26
003	2011-01-01	GREG SANDLIN	GREG SANDLIN	2012-10-14
003	2009-01-01	GREG SANDLIN	GREG SANDLIN	2012-10-15

Plan Statistics for 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC.

401k plan membership statisitcs for 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC.

Measure Date Value
2012: 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. 2012 401k membership
Total participants, beginning-of-year 2012-01-01 222
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 300
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 1
Total of all active and inactive participants 2012-01-01 301
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 301
Number of participants with account balances 2012-01-01 3
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. 2011 401k membership
Total participants, beginning-of-year 2011-01-01 248
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 280
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 1
Total of all active and inactive participants 2011-01-01 281
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 281
Number of participants with account balances 2011-01-01 3
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0
2009: 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. 2009 401k membership
Total participants, beginning-of-year 2009-01-01 212
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 224
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 1
Total of all active and inactive participants 2009-01-01 225
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 225
Number of participants with account balances 2009-01-01 2
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2012: 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. 2012 401k membership
Total participants, beginning-of-year	2012-01-01	222
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	300
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	1
Total of all active and inactive participants	2012-01-01	301
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	301
Number of participants with account balances	2012-01-01	3
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. 2011 401k membership
Total participants, beginning-of-year	2011-01-01	248
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	280
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	1
Total of all active and inactive participants	2011-01-01	281
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	281
Number of participants with account balances	2011-01-01	3
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2009: 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. 2009 401k membership
Total participants, beginning-of-year	2009-01-01	212
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	224
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	1
Total of all active and inactive participants	2009-01-01	225
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	225
Number of participants with account balances	2009-01-01	2
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC.

Measure	Date	Value
2012 : 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. 2012 401k financial data
Total unrealized appreciation/depreciation of assets	2012-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total income from all sources (including contributions)	2012-12-31	$3,277
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$0
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$2,100
Value of total assets at end of year	2012-12-31	$15,436
Value of total assets at beginning of year	2012-12-31	$12,159
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$0
Total interest from all sources	2012-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan	2012-12-31	$0
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$250,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$2,100
Participant contributions at beginning of year	2012-12-31	$100
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net income/loss	2012-12-31	$3,277
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$15,436
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$12,159
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Value of interest in pooled separate accounts at end of year	2012-12-31	$10,312
Value of interest in pooled separate accounts at beginning of year	2012-12-31	$8,098
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2012-12-31	$359
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2012-12-31	$365
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2012-12-31	$365
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$4,765
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$3,596
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2012-12-31	$1,177
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	No
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$15,436
Did the plan have assets held for investment	2012-12-31	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	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2012-12-31	Disclaimer
Accountancy firm name	2012-12-31	ALLEN, GIBBS & HOULIK, LC.
Accountancy firm EIN	2012-12-31	481032601
2011 : 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. 2011 401k financial data
Total unrealized appreciation/depreciation of assets	2011-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total income from all sources (including contributions)	2011-12-31	$5,792
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$0
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$6,000
Value of total assets at end of year	2011-12-31	$12,159
Value of total assets at beginning of year	2011-12-31	$6,367
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$0
Total interest from all sources	2011-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Was this plan covered by a fidelity bond	2011-12-31	No
If this is an individual account plan, was there a blackout period	2011-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$6,000
Participant contributions at end of year	2011-12-31	$100
Participant contributions at beginning of year	2011-12-31	$100
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Value of net income/loss	2011-12-31	$5,792
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$12,159
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$6,367
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-12-31	No
Were any leases to which the plan was party in default or uncollectible	2011-12-31	No
Value of interest in pooled separate accounts at end of year	2011-12-31	$8,098
Value of interest in pooled separate accounts at beginning of year	2011-12-31	$5,345
Value of interest in common/collective trusts at beginning of year	2011-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2011-12-31	$365
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2011-12-31	$371
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2011-12-31	$371
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-12-31	$3,596
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2011-12-31	$551
Net investment gain/loss from pooled separate accounts	2011-12-31	$-208
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-12-31	No
Was there a failure to transmit to the plan any participant contributions	2011-12-31	No
Has the plan failed to provide any benefit when due under the plan	2011-12-31	No
Did the plan have assets held for investment	2011-12-31	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	2011-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2011-12-31	Disclaimer
Accountancy firm name	2011-12-31	ALLEN, GIBBS & HOULIK, LC
Accountancy firm EIN	2011-12-31	481032601
2010 : 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. 2010 401k financial data
Total unrealized appreciation/depreciation of assets	2010-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$0
Total income from all sources (including contributions)	2010-12-31	$1,945
Total loss/gain on sale of assets	2010-12-31	$0
Total of all expenses incurred	2010-12-31	$0
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$1,200
Value of total assets at end of year	2010-12-31	$6,367
Value of total assets at beginning of year	2010-12-31	$4,422
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$0
Total interest from all sources	2010-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Was this plan covered by a fidelity bond	2010-12-31	No
If this is an individual account plan, was there a blackout period	2010-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$1,200
Participant contributions at end of year	2010-12-31	$100
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Value of net income/loss	2010-12-31	$1,945
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$6,367
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$4,422
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Value of interest in pooled separate accounts at end of year	2010-12-31	$5,345
Value of interest in pooled separate accounts at beginning of year	2010-12-31	$4,047
Value of interest in common/collective trusts at end of year	2010-12-31	$0
Value of interest in common/collective trusts at beginning of year	2010-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2010-12-31	$371
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2010-12-31	$375
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2010-12-31	$375
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$551
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$0
Net investment gain/loss from pooled separate accounts	2010-12-31	$745
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2010-12-31	No
Was there a failure to transmit to the plan any participant contributions	2010-12-31	No
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Did the plan have assets held for investment	2010-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2010-12-31	Disclaimer
Accountancy firm name	2010-12-31	ALLEN, GIBBS & HOULIK, LC
Accountancy firm EIN	2010-12-31	481032601

Form 5500 Responses for 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC.

2012: 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. 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: 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. 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 funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2009: 403B PLAN OF GOODWILL INDUSTRIES/EASTER SEAL SOCIETY OF KANSAS, INC. 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	First time form 5500 has been submitted	Yes
2009-01-01	Submission has been amended	Yes
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 funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

MUTUAL OF AMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88668 )

Policy contract number

012808-I

Policy instance

Insurance contract or identification number	012808-I
Number of Individuals Covered	3
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
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?	No
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?	No
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

MUTUAL OF AMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88668 )

Policy contract number

012808-I

Policy instance

Insurance contract or identification number	012808-I
Number of Individuals Covered	3
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
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?	No
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?	No
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

MUTUAL OF AMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88668 )

Policy contract number

012808-I

Policy instance

Insurance contract or identification number	012808-I
Number of Individuals Covered	3
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
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?	No
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?	No
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

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Company Name:	GOODWILL INDUSTRIES OF KANSAS, INC.
Employer identification number (EIN):	480673284
NAIC Classification:	813000
NAIC Description:	Religious, Grantmaking, Civic, Professional, and Similar Organizations