401k Plan data: THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN plan

THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 401k Plan overview

Plan Name	THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN
Plan identification number	001

THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
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.
Partial participant-directed account plan - Participants have the opportunity to direct the investment of a portion of 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.
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

FDIC AS RECEIVER FOR THE FIRST STATE BANK has sponsored the creation of one or more 401k plans.

Company Name: FDIC AS RECEIVER FOR THE FIRST STATE BANK

Employer identification number (EIN): 580943623

NAIC Classification: 522110
NAIC Description: Commercial Banking

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2013-01-01 MICHAEL L. SHEA FDIC AS RECEIVER 2013-12-30 MICHAEL L. SHEA FDIC AS RECEIVER 2013-12-30
001 2012-01-01 MICHAEL SHEA, AS FDIC RECIEVER MICHAEL SHEA, AS FDIC RECIEVER 2013-09-26
001 2011-01-01 MICHAEL L. SHEA FDIC AS RECEIVER MICHAEL L. SHEA FDIC AS RECEIVER 2012-10-12
001 2010-01-01 DEBBIE WALKER DEBBIE WALKER 2011-10-11
001 2009-01-01 DEBBIE WALKER DEBBIE WALKER 2010-10-05
001 2009-01-01 DEBBIE WALKER DEBBIE WALKER 2010-10-05

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2013-01-01	MICHAEL L. SHEA FDIC AS RECEIVER	2013-12-30	MICHAEL L. SHEA FDIC AS RECEIVER	2013-12-30
001	2012-01-01	MICHAEL SHEA, AS FDIC RECIEVER		MICHAEL SHEA, AS FDIC RECIEVER	2013-09-26
001	2011-01-01	MICHAEL L. SHEA FDIC AS RECEIVER		MICHAEL L. SHEA FDIC AS RECEIVER	2012-10-12
001	2010-01-01	DEBBIE WALKER		DEBBIE WALKER	2011-10-11
001	2009-01-01	DEBBIE WALKER		DEBBIE WALKER	2010-10-05
001	2009-01-01	DEBBIE WALKER		DEBBIE WALKER	2010-10-05

Plan Statistics for THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN

401k plan membership statisitcs for THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN

Measure Date Value
2012: THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 111
Number of other retired or separated participants entitled to future benefits 2012-01-01 99
Total of all active and inactive participants 2012-01-01 99
Total participants 2012-01-01 99
Number of participants with account balances 2012-01-01 99
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 111
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 103
Number of other retired or separated participants entitled to future benefits 2011-01-01 2
Total of all active and inactive participants 2011-01-01 105
Total participants 2011-01-01 105
Number of participants with account balances 2011-01-01 89
2010: THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 140
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 107
Number of retired or separated participants receiving benefits 2010-01-01 7
Number of other retired or separated participants entitled to future benefits 2010-01-01 4
Total of all active and inactive participants 2010-01-01 118
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
Total participants 2010-01-01 118
Number of participants with account balances 2010-01-01 110
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 2
2009: THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 150
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 110
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 25
Total of all active and inactive participants 2009-01-01 135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 135
Number of participants with account balances 2009-01-01 134
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 7

Measure	Date	Value
2012: THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	111
Number of other retired or separated participants entitled to future benefits	2012-01-01	99
Total of all active and inactive participants	2012-01-01	99
Total participants	2012-01-01	99
Number of participants with account balances	2012-01-01	99
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	111
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	103
Number of other retired or separated participants entitled to future benefits	2011-01-01	2
Total of all active and inactive participants	2011-01-01	105
Total participants	2011-01-01	105
Number of participants with account balances	2011-01-01	89
2010: THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	140
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	107
Number of retired or separated participants receiving benefits	2010-01-01	7
Number of other retired or separated participants entitled to future benefits	2010-01-01	4
Total of all active and inactive participants	2010-01-01	118
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	118
Number of participants with account balances	2010-01-01	110
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	2
2009: THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	150
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	110
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	25
Total of all active and inactive participants	2009-01-01	135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	135
Number of participants with account balances	2009-01-01	134
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	7

Financial Data on THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN

Measure	Date	Value
2012 : THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2012 401k financial data
Total income from all sources (including contributions)	2012-12-31	$298,772
Total of all expenses incurred	2012-12-31	$22,816
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$12,167
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$13,522
Value of total assets at end of year	2012-12-31	$3,386,917
Value of total assets at beginning of year	2012-12-31	$3,110,961
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$10,649
Total interest from all sources	2012-12-31	$2,810
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
Administrative expenses professional fees incurred	2012-12-31	$1,742
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$4,000,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Participant contributions at beginning of year	2012-12-31	$26,726
Participant contributions at beginning of year	2012-12-31	$6,694
Value of other receiveables (less allowance for doubtful accounts) at end of year	2012-12-31	$59
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2012-12-31	$446
Other income not declared elsewhere	2012-12-31	$34,313
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	$275,956
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$3,386,917
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$3,110,961
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 registered invesment companies (eg mutual funds) at end of year	2012-12-31	$2,024,884
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2012-12-31	$1,864,021
Interest on participant loans	2012-12-31	$140
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2012-12-31	$469,299
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2012-12-31	$445,557
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2012-12-31	$445,557
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2012-12-31	$2,670
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$892,675
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$767,517
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2012-12-31	$248,127
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
Contributions received in cash from employer	2012-12-31	$13,522
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$12,167
Contract administrator fees	2012-12-31	$8,907
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	MAULDIN & JENKINS
Accountancy firm EIN	2012-12-31	580692043
2011 : THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2011 401k financial data
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	$139,299
Total of all expenses incurred	2011-12-31	$633,941
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$623,393
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$161,090
Value of total assets at end of year	2011-12-31	$3,110,961
Value of total assets at beginning of year	2011-12-31	$3,605,603
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$10,548
Total interest from all sources	2011-12-31	$7,357
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Administrative expenses professional fees incurred	2011-12-31	$758
Was this plan covered by a fidelity bond	2011-12-31	Yes
Value of fidelity bond cover	2011-12-31	$4,000,000
If this is an individual account plan, was there a blackout period	2011-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2011-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$161,090
Participant contributions at end of year	2011-12-31	$26,726
Participant contributions at beginning of year	2011-12-31	$28,525
Participant contributions at end of year	2011-12-31	$6,694
Value of other receiveables (less allowance for doubtful accounts) at end of year	2011-12-31	$446
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2011-12-31	$2,160
Other income not declared elsewhere	2011-12-31	$-32,338
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	$-494,642
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$3,110,961
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$3,605,603
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
Investment advisory and management fees	2011-12-31	$1,651
Value of interest in registered invesment companies (eg mutual funds) at end of year	2011-12-31	$1,864,021
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2011-12-31	$2,030,213
Interest on participant loans	2011-12-31	$1,187
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2011-12-31	$445,557
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2011-12-31	$757,713
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2011-12-31	$757,713
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2011-12-31	$6,170
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-12-31	$767,517
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2011-12-31	$786,992
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2011-12-31	$3,190
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
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$623,393
Contract administrator fees	2011-12-31	$8,139
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	MAULDIN & JENKINS
Accountancy firm EIN	2011-12-31	580692043
2010 : THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 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	$487,359
Total loss/gain on sale of assets	2010-12-31	$0
Total of all expenses incurred	2010-12-31	$4,036,981
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$4,025,352
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$170,192
Value of total assets at end of year	2010-12-31	$3,605,603
Value of total assets at beginning of year	2010-12-31	$7,155,225
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$11,629
Total interest from all sources	2010-12-31	$75,569
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
Administrative expenses professional fees incurred	2010-12-31	$8,601
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$4,000,000
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	$170,192
Participant contributions at end of year	2010-12-31	$28,525
Participant contributions at beginning of year	2010-12-31	$20,627
Participant contributions at beginning of year	2010-12-31	$8,301
Value of other receiveables (less allowance for doubtful accounts) at end of year	2010-12-31	$2,160
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2010-12-31	$17,011
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2010-12-31	$0
Other income not declared elsewhere	2010-12-31	$30,148
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	$-3,549,622
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$3,605,603
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$7,155,225
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
Investment advisory and management fees	2010-12-31	$2,253
Value of interest in registered invesment companies (eg mutual funds) at end of year	2010-12-31	$2,030,213
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2010-12-31	$2,258,057
Interest on participant loans	2010-12-31	$1,216
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2010-12-31	$757,713
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2010-12-31	$4,033,649
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2010-12-31	$4,033,649
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2010-12-31	$74,353
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$786,992
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$817,580
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2010-12-31	$211,450
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
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$4,025,352
Contract administrator fees	2010-12-31	$775
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	MAULDIN & JENKINS, CPA
Accountancy firm EIN	2010-12-31	580692043
2009 : THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2009 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2009-12-31	$0

Form 5500 Responses for THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN

2012: THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2010: THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	Yes
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: THE FIRST STATE BANK PROFIT SHARING 401(K) PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	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

GAP-B2-SQ72

Policy instance

Insurance contract or identification number	GAP-B2-SQ72
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,236
Total amount of fees paid to insurance company	USD $559
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes

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

Policy contract number

GAP-B2-SQ72

Policy instance

Insurance contract or identification number	GAP-B2-SQ72
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,416
Total amount of fees paid to insurance company	USD $604
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
Commission paid to Insurance Broker	USD $2,416
Insurance broker organization code?	3
Amount paid for insurance broker fees	604
Additional information about fees paid to insurance broker	ADMINISTRATIVE
Insurance broker name	PENSION FINANCIAL SERVICES INC.

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Company Name:	FDIC AS RECEIVER FOR THE FIRST STATE BANK
Employer identification number (EIN):	580943623
NAIC Classification:	522110
NAIC Description:	Commercial Banking