401k Plan data: CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B) plan

CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B) 401k Plan overview

Plan Name	CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B)
Plan identification number	001

CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B) Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

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.
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 403(b)(1) arrangement - See Limited Pension Plan Reporting instructions for Code section 403(b)(1) arrangements for certain exempt organizations.
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.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

CENTRAL GEORGIA CENTRAL HEALTH, INC has sponsored the creation of one or more 401k plans.

Company Name: CENTRAL GEORGIA CENTRAL HEALTH, INC

Employer identification number (EIN): 582345439

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B)

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2012-01-01 CONNIE JONES 2012-10-16
001 2011-01-01 CONNIE JONES
001 2009-01-01 CONNIE JONES THOMAS ROCKENBACH 2010-10-15
001 2009-01-01 CONNIE JONES C0NNIE JONES 2010-10-14
001 2009-01-01 CONNIE JONES THOMAS ROCHENBACH 2010-10-15
001 2009-01-01 CONNIE JONES
001 2009-01-01 CONNIE JONES CONNIE JONES 2010-10-15
001 2009-01-01 CONNIE JONES THOMAS ROCHENBACH 2010-10-15

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2012-01-01	CONNIE JONES	2012-10-16
001	2011-01-01	CONNIE JONES
001	2009-01-01	CONNIE JONES		THOMAS ROCKENBACH	2010-10-15
001	2009-01-01	CONNIE JONES		C0NNIE JONES	2010-10-14
001	2009-01-01	CONNIE JONES		THOMAS ROCHENBACH	2010-10-15
001	2009-01-01	CONNIE JONES
001	2009-01-01	CONNIE JONES		CONNIE JONES	2010-10-15
001	2009-01-01	CONNIE JONES		THOMAS ROCHENBACH	2010-10-15

Plan Statistics for CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B)

401k plan membership statisitcs for CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B)

Measure Date Value
2011: CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B) 2011 401k membership
Total participants, beginning-of-year 2011-01-01 229
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 0
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 81
Total of all active and inactive participants 2011-01-01 81
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 81
Number of participants with account balances 2011-01-01 81
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0
2009: CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B) 2009 401k membership
Total participants, beginning-of-year 2009-01-01 163
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 225
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 0
Total of all active and inactive participants 2009-01-01 225
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 225
Number of participants with account balances 2009-01-01 73
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2011: CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B) 2011 401k membership
Total participants, beginning-of-year	2011-01-01	229
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	0
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	81
Total of all active and inactive participants	2011-01-01	81
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	81
Number of participants with account balances	2011-01-01	81
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2009: CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B) 2009 401k membership
Total participants, beginning-of-year	2009-01-01	163
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	225
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	0
Total of all active and inactive participants	2009-01-01	225
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	225
Number of participants with account balances	2009-01-01	73
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B)

Measure	Date	Value
2011 : CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B) 2011 401k financial data
Total unrealized appreciation/depreciation of assets	2011-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total income from all sources (including contributions)	2011-12-31	$94,938
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$29,282
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$27,437
Expenses. Certain deemed distributions of participant loans	2011-12-31	$1,845
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$93,874
Value of total assets at end of year	2011-12-31	$447,435
Value of total assets at beginning of year	2011-12-31	$381,779
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$0
Total interest from all sources	2011-12-31	$6,088
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Was this plan covered by a fidelity bond	2011-12-31	Yes
Value of fidelity bond cover	2011-12-31	$10,000,000
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	$66,588
Participant contributions at end of year	2011-12-31	$24,220
Participant contributions at beginning of year	2011-12-31	$3,992
Income. Received or receivable in cash from other sources (including rollovers)	2011-12-31	$12,630
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	$65,656
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$447,435
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$381,779
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-12-31	No
Were any leases to which the plan was party in default or uncollectible	2011-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2011-12-31	$228,477
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2011-12-31	$216,778
Interest on participant loans	2011-12-31	$438
Interest earned on other investments	2011-12-31	$5,650
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-12-31	$194,738
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2011-12-31	$161,009
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2011-12-31	$-5,024
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
Contributions received in cash from employer	2011-12-31	$14,656
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$27,437
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2011-12-31	No
Did the plan have assets held for investment	2011-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2011-12-31	Disclaimer
Accountancy firm name	2011-12-31	HOWARD, MOORE & MCDUFFIE, P.C.
Accountancy firm EIN	2011-12-31	581484212
2010 : CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B) 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	$161,029
Total loss/gain on sale of assets	2010-12-31	$0
Total of all expenses incurred	2010-12-31	$18,757
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$17,023
Expenses. Certain deemed distributions of participant loans	2010-12-31	$1,734
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$131,850
Value of total assets at end of year	2010-12-31	$381,779
Value of total assets at beginning of year	2010-12-31	$239,507
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$0
Total interest from all sources	2010-12-31	$4,500
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$10,000,000
If this is an individual account plan, was there a blackout period	2010-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$91,330
Participant contributions at end of year	2010-12-31	$3,992
Participant contributions at beginning of year	2010-12-31	$1,050
Income. Received or receivable in cash from other sources (including rollovers)	2010-12-31	$21,877
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	$142,272
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$381,779
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$239,507
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2010-12-31	$216,778
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2010-12-31	$136,344
Interest on participant loans	2010-12-31	$94
Interest earned on other investments	2010-12-31	$4,406
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$161,009
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$102,113
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2010-12-31	$24,679
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
Contributions received in cash from employer	2010-12-31	$18,643
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$17,023
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2010-12-31	No
Did the plan have assets held for investment	2010-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2010-12-31	Disclaimer
Accountancy firm name	2010-12-31	HOWARD, MOORE, MCDUFFIE
Accountancy firm EIN	2010-12-31	581484212

Form 5500 Responses for CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B)

2011: CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B) 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: CENTRAL GEORGIA SENIOR HEALTH, INC. 403(B) 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

VARIABLE ANNUITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70238 )

Policy contract number

63667

Policy instance

Insurance contract or identification number	63667
Number of Individuals Covered	81
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,403
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	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

VARIABLE ANNUITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70238 )

Policy contract number

63667

Policy instance

Insurance contract or identification number	63667
Number of Individuals Covered	78
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,236
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	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:	CENTRAL GEORGIA CENTRAL HEALTH, INC
Employer identification number (EIN):	582345439
NAIC Classification:	622000
NAIC Description:	Hospitals