401k Plan data: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN plan

TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 401k Plan overview

Plan Name	TRI-STATE PETROLEUM CORPORATION 401(K) PLAN
Plan identification number	001

TRI-STATE PETROLEUM CORPORATION 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.
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.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

TRI-STATE PETROLEUM CORPORATION has sponsored the creation of one or more 401k plans.

Company Name: TRI-STATE PETROLEUM CORPORATION

Employer identification number (EIN): 550544468

NAIC Classification: 447100
NAIC Description: Gasoline Stations, Gas

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TRI-STATE PETROLEUM CORPORATION 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 ERIN C. MERRICK 2022-08-16
001 2021-01-01
001 2020-01-01
001 2019-01-01
001 2018-01-01
001 2017-01-01 ERIN C MERRICK
001 2016-01-01 ERIN C MERRICK
001 2015-01-01 ERIN C MERRICK
001 2014-01-01 ERIN C MERRICK

Plan Statistics for TRI-STATE PETROLEUM CORPORATION 401(K) PLAN

401k plan membership statisitcs for TRI-STATE PETROLEUM CORPORATION 401(K) PLAN

Measure Date Value
2021: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 130
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 9
Number of retired or separated participants receiving benefits 2021-01-01 40
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 49
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 49
Number of participants with account balances 2021-01-01 42
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0
2020: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 126
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 112
Number of retired or separated participants receiving benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 112
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 5
Total participants 2020-01-01 117
Number of participants with account balances 2020-01-01 39
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 108
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 4
Total of all active and inactive participants 2019-01-01 112
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 112
Number of participants with account balances 2019-01-01 37
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 2
2018: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 145
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 108
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 6
Total of all active and inactive participants 2018-01-01 114
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 114
Number of participants with account balances 2018-01-01 39
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 7
2017: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 151
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 125
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 6
Total of all active and inactive participants 2017-01-01 131
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 131
Number of participants with account balances 2017-01-01 40
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 4
2016: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 136
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 122
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 4
Total of all active and inactive participants 2016-01-01 126
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 126
Number of participants with account balances 2016-01-01 41
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 1
2015: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 125
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 114
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 3
Total of all active and inactive participants 2015-01-01 117
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 117
Number of participants with account balances 2015-01-01 27
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 1
2014: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 157
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 96
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 4
Total of all active and inactive participants 2014-01-01 100
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 100
Number of participants with account balances 2014-01-01 30
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 17

Measure	Date	Value
2021: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	130
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	9
Number of retired or separated participants receiving benefits	2021-01-01	40
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	49
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	49
Number of participants with account balances	2021-01-01	42
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
2020: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	126
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	112
Number of retired or separated participants receiving benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	112
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	5
Total participants	2020-01-01	117
Number of participants with account balances	2020-01-01	39
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	108
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	4
Total of all active and inactive participants	2019-01-01	112
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	112
Number of participants with account balances	2019-01-01	37
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	2
2018: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	145
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	108
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	6
Total of all active and inactive participants	2018-01-01	114
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	114
Number of participants with account balances	2018-01-01	39
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	7
2017: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	151
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	125
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	6
Total of all active and inactive participants	2017-01-01	131
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	131
Number of participants with account balances	2017-01-01	40
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	4
2016: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	136
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	122
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	4
Total of all active and inactive participants	2016-01-01	126
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	126
Number of participants with account balances	2016-01-01	41
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	1
2015: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	125
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	114
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	3
Total of all active and inactive participants	2015-01-01	117
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	117
Number of participants with account balances	2015-01-01	27
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	1
2014: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	157
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	96
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	4
Total of all active and inactive participants	2014-01-01	100
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	100
Number of participants with account balances	2014-01-01	30
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	17

Financial Data on TRI-STATE PETROLEUM CORPORATION 401(K) PLAN

Measure	Date	Value
2021 : TRI-STATE PETROLEUM CORPORATION 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	$226,924
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$79,323
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$61,014
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$145,545
Value of total assets at end of year	2021-12-31	$767,545
Value of total assets at beginning of year	2021-12-31	$619,944
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$18,309
Total interest from all sources	2021-12-31	$0
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
Administrative expenses professional fees incurred	2021-12-31	$18,309
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$250,000
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	$105,428
Participant contributions at end of year	2021-12-31	$0
Participant contributions at beginning of year	2021-12-31	$3,645
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2021-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2021-12-31	$0
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
Income. Non cash contributions	2021-12-31	$0
Value of net income/loss	2021-12-31	$147,601
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$767,545
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$619,944
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 registered invesment companies (eg mutual funds) at end of year	2021-12-31	$767,545
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$614,873
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$81,379
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
Contributions received in cash from employer	2021-12-31	$40,117
Employer contributions (assets) at end of year	2021-12-31	$0
Employer contributions (assets) at beginning of year	2021-12-31	$1,426
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$61,014
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	HILL BARTH & KING LLC
Accountancy firm EIN	2021-12-31	341897225
2020 : TRI-STATE PETROLEUM CORPORATION 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
Expenses. Interest paid	2020-12-31	$14,169
Amount of participant contributions which was failed to transmit to the plan within the time period described in 29 CFR 251.3-102	2020-12-31	$14,169
Total income from all sources (including contributions)	2020-12-31	$169,518
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$89,113
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$74,944
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$127,865
Value of total assets at end of year	2020-12-31	$619,944
Value of total assets at beginning of year	2020-12-31	$539,539
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$0
Total interest from all sources	2020-12-31	$0
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
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$250,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$91,404
Participant contributions at end of year	2020-12-31	$3,645
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	$80,405
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$619,944
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$539,539
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 registered invesment companies (eg mutual funds) at end of year	2020-12-31	$614,873
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$539,539
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$41,653
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	Yes
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$36,461
Employer contributions (assets) at end of year	2020-12-31	$1,426
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$74,944
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	HILL BARTH & KING LLC
Accountancy firm EIN	2020-12-31	341897225
2019 : TRI-STATE PETROLEUM CORPORATION 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	$205,797
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$61,066
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$46,752
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$109,325
Value of total assets at end of year	2019-12-31	$539,539
Value of total assets at beginning of year	2019-12-31	$394,808
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$14,314
Total interest from all sources	2019-12-31	$0
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	$250,000
If this is an individual account plan, was there a blackout period	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Contributions received from participants	2019-12-31	$77,568
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	$144,731
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$539,539
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$394,808
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
Investment advisory and management fees	2019-12-31	$10,957
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$539,539
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$394,808
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$96,472
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
Contributions received in cash from employer	2019-12-31	$31,757
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$46,752
Contract administrator fees	2019-12-31	$3,357
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	HILL BARTH & KING LLC
Accountancy firm EIN	2019-12-31	341897225
2018 : TRI-STATE PETROLEUM CORPORATION 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	$79,996
Total loss/gain on sale of assets	2018-12-31	$0
Total of all expenses incurred	2018-12-31	$36,154
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$23,776
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$107,137
Value of total assets at end of year	2018-12-31	$394,808
Value of total assets at beginning of year	2018-12-31	$350,966
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$12,378
Total interest from all sources	2018-12-31	$0
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	$100,000
If this is an individual account plan, was there a blackout period	2018-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Contributions received from participants	2018-12-31	$73,985
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	$43,842
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$394,808
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$350,966
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
Investment advisory and management fees	2018-12-31	$9,055
Value of interest in registered invesment companies (eg mutual funds) at end of year	2018-12-31	$394,808
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2018-12-31	$350,966
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-12-31	$-27,141
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
Contributions received in cash from employer	2018-12-31	$33,152
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$23,776
Contract administrator fees	2018-12-31	$3,323
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	HILL BARTH & KING LLC
Accountancy firm EIN	2018-12-31	341897225
2017 : TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2017 401k financial data
Total unrealized appreciation/depreciation of assets	2017-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total income from all sources (including contributions)	2017-12-31	$114,633
Total loss/gain on sale of assets	2017-12-31	$0
Total of all expenses incurred	2017-12-31	$41,260
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$30,826
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$64,675
Value of total assets at end of year	2017-12-31	$350,966
Value of total assets at beginning of year	2017-12-31	$277,593
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$10,434
Total interest from all sources	2017-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2017-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-12-31	No
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$100,000
If this is an individual account plan, was there a blackout period	2017-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Contributions received from participants	2017-12-31	$64,606
Administrative expenses (other) incurred	2017-12-31	$7,136
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Value of net income/loss	2017-12-31	$73,373
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$350,966
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$277,593
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-12-31	No
Were any leases to which the plan was party in default or uncollectible	2017-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2017-12-31	$350,966
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2017-12-31	$277,593
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2017-12-31	$49,958
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-12-31	No
Was there a failure to transmit to the plan any participant contributions	2017-12-31	No
Has the plan failed to provide any benefit when due under the plan	2017-12-31	No
Contributions received in cash from employer	2017-12-31	$69
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$30,826
Contract administrator fees	2017-12-31	$3,298
Did the plan have assets held for investment	2017-12-31	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	2017-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2017-12-31	Disclaimer
Accountancy firm name	2017-12-31	HILL BARTH & KING LLC
Accountancy firm EIN	2017-12-31	341897225
2016 : TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2016 401k financial data
Total unrealized appreciation/depreciation of assets	2016-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$0
Total income from all sources (including contributions)	2016-12-31	$173,676
Total loss/gain on sale of assets	2016-12-31	$0
Total of all expenses incurred	2016-12-31	$11,569
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$3,263
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$150,031
Value of total assets at end of year	2016-12-31	$277,593
Value of total assets at beginning of year	2016-12-31	$115,486
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$8,306
Total interest from all sources	2016-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2016-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-12-31	No
Was this plan covered by a fidelity bond	2016-12-31	Yes
Value of fidelity bond cover	2016-12-31	$25,000
If this is an individual account plan, was there a blackout period	2016-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2016-12-31	No
Contributions received from participants	2016-12-31	$64,095
Participant contributions at beginning of year	2016-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2016-12-31	$55,856
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Income. Non cash contributions	2016-12-31	$0
Value of net income/loss	2016-12-31	$162,107
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$277,593
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$115,486
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-12-31	No
Were any leases to which the plan was party in default or uncollectible	2016-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2016-12-31	$277,593
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2016-12-31	$115,486
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2016-12-31	$23,645
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-12-31	No
Was there a failure to transmit to the plan any participant contributions	2016-12-31	No
Has the plan failed to provide any benefit when due under the plan	2016-12-31	No
Contributions received in cash from employer	2016-12-31	$30,080
Employer contributions (assets) at beginning of year	2016-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$3,263
Contract administrator fees	2016-12-31	$8,306
Did the plan have assets held for investment	2016-12-31	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	2016-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2016-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2016-12-31	Disclaimer
Accountancy firm name	2016-12-31	HILL BARTH & KING LLC
Accountancy firm EIN	2016-12-31	341897225
2015 : TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2015 401k financial data
Total unrealized appreciation/depreciation of assets	2015-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total income from all sources (including contributions)	2015-12-31	$56,016
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$17,208
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$12,495
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$56,598
Value of total assets at end of year	2015-12-31	$115,486
Value of total assets at beginning of year	2015-12-31	$76,678
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$4,713
Total interest from all sources	2015-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$25,000
If this is an individual account plan, was there a blackout period	2015-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2015-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$37,732
Participant contributions at end of year	2015-12-31	$0
Participant contributions at beginning of year	2015-12-31	$6,201
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Value of net income/loss	2015-12-31	$38,808
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$115,486
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$76,678
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-12-31	No
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Investment advisory and management fees	2015-12-31	$4,713
Value of interest in registered invesment companies (eg mutual funds) at end of year	2015-12-31	$115,486
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2015-12-31	$68,469
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2015-12-31	$-582
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-12-31	No
Was there a failure to transmit to the plan any participant contributions	2015-12-31	No
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Contributions received in cash from employer	2015-12-31	$18,866
Employer contributions (assets) at end of year	2015-12-31	$0
Employer contributions (assets) at beginning of year	2015-12-31	$2,008
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$12,495
Did the plan have assets held for investment	2015-12-31	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	2015-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2015-12-31	Disclaimer
Accountancy firm name	2015-12-31	HILL BARTH & KING LLC
Accountancy firm EIN	2015-12-31	341897225
2014 : TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2014 401k financial data
Total unrealized appreciation/depreciation of assets	2014-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total income from all sources (including contributions)	2014-12-31	$90,823
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$14,145
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$12,445
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$89,379
Value of total assets at end of year	2014-12-31	$76,678
Value of total assets at beginning of year	2014-12-31	$0
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$1,700
Total interest from all sources	2014-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Was this plan covered by a fidelity bond	2014-12-31	No
If this is an individual account plan, was there a blackout period	2014-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$61,141
Participant contributions at end of year	2014-12-31	$6,201
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Value of net income/loss	2014-12-31	$76,678
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$76,678
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-12-31	No
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2014-12-31	$68,469
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2014-12-31	$1,444
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-12-31	No
Was there a failure to transmit to the plan any participant contributions	2014-12-31	No
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Contributions received in cash from employer	2014-12-31	$28,238
Employer contributions (assets) at end of year	2014-12-31	$2,008
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$12,445
Contract administrator fees	2014-12-31	$1,700
Did the plan have assets held for investment	2014-12-31	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	2014-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2014-12-31	Disclaimer
Accountancy firm name	2014-12-31	HILL BARTH & KING LLC
Accountancy firm EIN	2014-12-31	341897225

Form 5500 Responses for TRI-STATE PETROLEUM CORPORATION 401(K) PLAN

2021: TRI-STATE PETROLEUM CORPORATION 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: TRI-STATE PETROLEUM CORPORATION 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: TRI-STATE PETROLEUM CORPORATION 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 – Trust	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: TRI-STATE PETROLEUM CORPORATION 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 – Trust	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: TRI-STATE PETROLEUM CORPORATION 401(K) PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	First time form 5500 has been submitted	Yes
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	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

222-80315

Policy instance

Insurance contract or identification number	222-80315
Number of Individuals Covered	49
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $676
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?	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 $676
Insurance broker organization code?	4

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

Policy contract number

222-80315

Policy instance

Insurance contract or identification number	222-80315
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $478
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?	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
Commission paid to Insurance Broker	USD $247
Amount paid for insurance broker fees	0
Insurance broker organization code?	4

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Company Name:	TRI-STATE PETROLEUM CORPORATION
Employer identification number (EIN):	550544468
NAIC Classification:	447100
NAIC Description:	Gasoline Stations, Gas

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
001	2022-01-01	ERIN C. MERRICK	2022-08-16
001	2021-01-01
001	2020-01-01
001	2019-01-01
001	2018-01-01
001	2017-01-01	ERIN C MERRICK
001	2016-01-01	ERIN C MERRICK
001	2015-01-01	ERIN C MERRICK
001	2014-01-01	ERIN C MERRICK