401k Plan data: MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN plan

MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN 401k Plan overview

Plan Name	MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN
Plan identification number	002

MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS 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.
Plan provides for automatic enrollment in plan that has employee contributions deducted from payroll.
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.

401k Sponsoring company profile

MEDSOURCE COMMUNITY SERVICES, INC. has sponsored the creation of one or more 401k plans.

Company Name: MEDSOURCE COMMUNITY SERVICES, INC.

Employer identification number (EIN): 521479917

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2021-07-01
002 2021-07-01
002 2020-07-01
002 2019-07-01
002 2019-07-01
002 2018-07-01
002 2017-07-01
002 2016-07-01
002 2015-07-01 HAROLD BRANDENBURG 2016-11-16
002 2014-07-01 HAROLD BRANDENBURG 2016-01-27
002 2013-07-01 HAROLD BRANDENBURG 2015-04-15
002 2012-07-01 HAROLD BRANDENBURG 2014-04-11
002 2011-07-01 HAROLD BRANDENBURG 2013-04-11
002 2010-07-01 HAROLD BRANDENBURG 2012-01-31

Plan Statistics for MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN

401k plan membership statisitcs for MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN

Measure Date Value
2021: MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 166
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 131
Number of retired or separated participants receiving benefits 2021-07-01 0
Number of other retired or separated participants entitled to future benefits 2021-07-01 71
Total of all active and inactive participants 2021-07-01 202
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-07-01 0
Total participants 2021-07-01 202
Number of participants with account balances 2021-07-01 179
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-07-01 0
2020: MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 148
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 121
Number of retired or separated participants receiving benefits 2020-07-01 0
Number of other retired or separated participants entitled to future benefits 2020-07-01 45
Total of all active and inactive participants 2020-07-01 166
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-07-01 0
Total participants 2020-07-01 166
Number of participants with account balances 2020-07-01 161
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-07-01 0
2019: MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 116
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 121
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 27
Total of all active and inactive participants 2019-07-01 148
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-07-01 0
Total participants 2019-07-01 148
Number of participants with account balances 2019-07-01 142
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-07-01 0

Measure	Date	Value
2021: MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	166
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	131
Number of retired or separated participants receiving benefits	2021-07-01	0
Number of other retired or separated participants entitled to future benefits	2021-07-01	71
Total of all active and inactive participants	2021-07-01	202
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-07-01	0
Total participants	2021-07-01	202
Number of participants with account balances	2021-07-01	179
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-07-01	0
2020: MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	148
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	121
Number of retired or separated participants receiving benefits	2020-07-01	0
Number of other retired or separated participants entitled to future benefits	2020-07-01	45
Total of all active and inactive participants	2020-07-01	166
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-07-01	0
Total participants	2020-07-01	166
Number of participants with account balances	2020-07-01	161
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-07-01	0
2019: MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	116
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	121
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	27
Total of all active and inactive participants	2019-07-01	148
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-07-01	0
Total participants	2019-07-01	148
Number of participants with account balances	2019-07-01	142
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-07-01	0

Financial Data on MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN

Measure	Date	Value
2022 : MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-06-30	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-06-30	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-06-30	$0
Total income from all sources (including contributions)	2022-06-30	$-45,464
Total loss/gain on sale of assets	2022-06-30	$0
Total of all expenses incurred	2022-06-30	$61,386
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-06-30	$60,632
Expenses. Certain deemed distributions of participant loans	2022-06-30	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-06-30	$355,772
Value of total assets at end of year	2022-06-30	$2,627,478
Value of total assets at beginning of year	2022-06-30	$2,734,328
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-06-30	$754
Total interest from all sources	2022-06-30	$2,799
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	$269,990
Participant contributions at end of year	2022-06-30	$108,615
Participant contributions at beginning of year	2022-06-30	$45,956
Participant contributions at end of year	2022-06-30	$20,631
Participant contributions at beginning of year	2022-06-30	$0
Income. Received or receivable in cash from other sources (including rollovers)	2022-06-30	$24,594
Other income not declared elsewhere	2022-06-30	$0
Administrative expenses (other) incurred	2022-06-30	$754
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	$-106,850
Value of net assets at end of year (total assets less liabilities)	2022-06-30	$2,627,478
Value of net assets at beginning of year (total assets less liabilities)	2022-06-30	$2,734,328
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	$2,136,881
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-06-30	$2,321,234
Value of interest in pooled separate accounts at end of year	2022-06-30	$2,136,881
Value of interest in pooled separate accounts at beginning of year	2022-06-30	$2,321,234
Interest on participant loans	2022-06-30	$572
Interest earned on other investments	2022-06-30	$2,227
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-06-30	$381,982
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-06-30	$340,598
Expenses. Payments to insurance carriers foe the provision of benefits	2022-06-30	$0
Net investment gain/loss from pooled separate accounts	2022-06-30	$-404,035
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	$61,188
Employer contributions (assets) at end of year	2022-06-30	$0
Employer contributions (assets) at beginning of year	2022-06-30	$26,540
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-06-30	$60,632
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	Disclaimer
Accountancy firm name	2022-06-30	MULLEN SONDBERG WIMBISH & STONE
Accountancy firm EIN	2022-06-30	521197902
2021 : MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS 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	$834,527
Total loss/gain on sale of assets	2021-06-30	$0
Total of all expenses incurred	2021-06-30	$71,524
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-06-30	$70,719
Expenses. Certain deemed distributions of participant loans	2021-06-30	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-06-30	$309,289
Value of total assets at end of year	2021-06-30	$2,734,328
Value of total assets at beginning of year	2021-06-30	$1,971,325
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-06-30	$805
Total interest from all sources	2021-06-30	$4,742
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	$243,970
Participant contributions at end of year	2021-06-30	$45,956
Participant contributions at beginning of year	2021-06-30	$26,198
Income. Received or receivable in cash from other sources (including rollovers)	2021-06-30	$0
Other income not declared elsewhere	2021-06-30	$0
Administrative expenses (other) incurred	2021-06-30	$805
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	$763,003
Value of net assets at end of year (total assets less liabilities)	2021-06-30	$2,734,328
Value of net assets at beginning of year (total assets less liabilities)	2021-06-30	$1,971,325
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	$2,321,234
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-06-30	$1,625,726
Interest on participant loans	2021-06-30	$1,548
Interest earned on other investments	2021-06-30	$3,194
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-06-30	$340,598
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-06-30	$302,754
Expenses. Payments to insurance carriers foe the provision of benefits	2021-06-30	$0
Net investment gain/loss from pooled separate accounts	2021-06-30	$520,496
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	Yes
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	$65,319
Employer contributions (assets) at end of year	2021-06-30	$26,540
Employer contributions (assets) at beginning of year	2021-06-30	$16,647
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-06-30	$70,719
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	MULLEN SONDBERG WIMBISH & STONE,PA
Accountancy firm EIN	2021-06-30	521197902
2020 : MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS 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	$363,999
Total loss/gain on sale of assets	2020-06-30	$0
Total of all expenses incurred	2020-06-30	$118,956
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-06-30	$115,029
Expenses. Certain deemed distributions of participant loans	2020-06-30	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-06-30	$302,843
Value of total assets at end of year	2020-06-30	$1,954,678
Value of total assets at beginning of year	2020-06-30	$1,709,635
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-06-30	$3,927
Total interest from all sources	2020-06-30	$4,179
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	$200,000
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	$199,490
Participant contributions at end of year	2020-06-30	$26,198
Participant contributions at beginning of year	2020-06-30	$0
Participant contributions at end of year	2020-06-30	$26,198
Income. Received or receivable in cash from other sources (including rollovers)	2020-06-30	$64,561
Other income not declared elsewhere	2020-06-30	$0
Administrative expenses (other) incurred	2020-06-30	$3,927
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
Value of net income/loss	2020-06-30	$245,043
Value of net assets at end of year (total assets less liabilities)	2020-06-30	$1,954,678
Value of net assets at beginning of year (total assets less liabilities)	2020-06-30	$1,709,635
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	$1,625,726
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-06-30	$1,709,635
Interest on participant loans	2020-06-30	$673
Interest earned on other investments	2020-06-30	$3,506
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-06-30	$302,754
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-06-30	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2020-06-30	$0
Net investment gain/loss from pooled separate accounts	2020-06-30	$56,977
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	$38,792
Employer contributions (assets) at end of year	2020-06-30	$16,647
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-06-30	$115,029
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	MULLEN SONDBERG WIMBISH & STONE
Accountancy firm EIN	2020-06-30	521197902

Form 5500 Responses for MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN

2021: MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single 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 benefit arrangement – Insurance	Yes
2020: MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single 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 benefit arrangement – Insurance	Yes
2019: MEDSOURCE COMMUNITY SERVICES 401(K) SAVINGS PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single 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 benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

061928K

Policy instance

Insurance contract or identification number	061928K
Number of Individuals Covered	0
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $3,709
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	1
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	3709
Additional information about fees paid to insurance broker	PORTION OF INCENTIVE COMP. PROGRAM
Insurance broker organization code?	3

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

Policy contract number

061928K

Policy instance

Insurance contract or identification number	061928K
Number of Individuals Covered	166
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $3,709
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	1
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	3709
Additional information about fees paid to insurance broker	PORTION OF INCENTIVE COMP. PROGRAM
Insurance broker organization code?	3

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

Policy contract number

061928K

Policy instance

Insurance contract or identification number	061928K
Number of Individuals Covered	148
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
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	1
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	MEDSOURCE COMMUNITY SERVICES, INC.
Employer identification number (EIN):	521479917
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities