401k Plan data: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN plan

JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 401k Plan overview

Plan Name	JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN
Plan identification number	001

JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT 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.
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.
Participant-directed brokerage accounts provided as an investment option under the plan.
Life insurance

401k Sponsoring company profile

JEFFERSON-SHELBY SURGICAL AFFILIATES PC has sponsored the creation of one or more 401k plans.

Company Name: JEFFERSON-SHELBY SURGICAL AFFILIATES PC

Employer identification number (EIN): 630967549

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2018-01-01
001 2016-01-01 JERRY NICHOLAS 2017-06-27
001 2015-01-01 JERRY NICHOLAS 2016-05-12
001 2014-01-01 JERRY NICHOLAS JERRY NICHOLAS 2015-05-28
001 2013-01-01 JERRY NICHOLAS JERRY NICHOLAS 2015-05-28
001 2012-01-01 E. DOUGLAS PARKER
001 2011-01-01 WILLIAM SCOFIELD
001 2010-01-01 WILLIAM SCOFIELD
001 2009-01-01 WILLIAM SCOFIELD

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2018-01-01
001	2016-01-01	JERRY NICHOLAS	2017-06-27
001	2015-01-01	JERRY NICHOLAS	2016-05-12
001	2014-01-01	JERRY NICHOLAS		JERRY NICHOLAS	2015-05-28
001	2013-01-01	JERRY NICHOLAS		JERRY NICHOLAS	2015-05-28
001	2012-01-01	E. DOUGLAS PARKER
001	2011-01-01	WILLIAM SCOFIELD
001	2010-01-01	WILLIAM SCOFIELD
001	2009-01-01	WILLIAM SCOFIELD

Plan Statistics for JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN

401k plan membership statisitcs for JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN

Measure Date Value
2014: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 8
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 4
Number of retired or separated participants receiving benefits 2014-01-01 1
Total of all active and inactive participants 2014-01-01 5
Total participants 2014-01-01 5
Number of participants with account balances 2014-01-01 5
2013: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 10
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 5
Number of retired or separated participants receiving benefits 2013-01-01 2
Number of other retired or separated participants entitled to future benefits 2013-01-01 1
Total of all active and inactive participants 2013-01-01 8
Total participants 2013-01-01 8
2012: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 10
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 7
Number of retired or separated participants receiving benefits 2012-01-01 1
Number of other retired or separated participants entitled to future benefits 2012-01-01 2
Total of all active and inactive participants 2012-01-01 10
Total participants 2012-01-01 10
Number of participants with account balances 2012-01-01 10
2011: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 10
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 7
Number of retired or separated participants receiving benefits 2011-01-01 1
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 10
Total participants 2011-01-01 10
Number of participants with account balances 2011-01-01 10
2010: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 10
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 7
Number of other retired or separated participants entitled to future benefits 2010-01-01 3
Total of all active and inactive participants 2010-01-01 10
Total participants 2010-01-01 10
Number of participants with account balances 2010-01-01 10
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 0
2009: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 9
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 9
Number of other retired or separated participants entitled to future benefits 2009-01-01 1
Total of all active and inactive participants 2009-01-01 10
Total participants 2009-01-01 10
Number of participants with account balances 2009-01-01 10

Measure	Date	Value
2014: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	8
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	4
Number of retired or separated participants receiving benefits	2014-01-01	1
Total of all active and inactive participants	2014-01-01	5
Total participants	2014-01-01	5
Number of participants with account balances	2014-01-01	5
2013: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	10
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	5
Number of retired or separated participants receiving benefits	2013-01-01	2
Number of other retired or separated participants entitled to future benefits	2013-01-01	1
Total of all active and inactive participants	2013-01-01	8
Total participants	2013-01-01	8
2012: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	10
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	7
Number of retired or separated participants receiving benefits	2012-01-01	1
Number of other retired or separated participants entitled to future benefits	2012-01-01	2
Total of all active and inactive participants	2012-01-01	10
Total participants	2012-01-01	10
Number of participants with account balances	2012-01-01	10
2011: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	10
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	7
Number of retired or separated participants receiving benefits	2011-01-01	1
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	10
Total participants	2011-01-01	10
Number of participants with account balances	2011-01-01	10
2010: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	10
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	7
Number of other retired or separated participants entitled to future benefits	2010-01-01	3
Total of all active and inactive participants	2010-01-01	10
Total participants	2010-01-01	10
Number of participants with account balances	2010-01-01	10
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	0
2009: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	9
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	9
Number of other retired or separated participants entitled to future benefits	2009-01-01	1
Total of all active and inactive participants	2009-01-01	10
Total participants	2009-01-01	10
Number of participants with account balances	2009-01-01	10

Financial Data on JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN

Measure	Date	Value
2014 : JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2014 401k financial data
Transfers to/from the plan	2014-12-31	$-20,235
Total income from all sources	2014-12-31	$74,726
Expenses. Total of all expenses incurred	2014-12-31	$4,576
Total plan assets at end of year	2014-12-31	$2,053,172
Total plan assets at beginning of year	2014-12-31	$2,003,257
Value of fidelity bond covering the plan	2014-12-31	$350,000
Total contributions received or receivable from participants	2014-12-31	$17,424
Other income received	2014-12-31	$57,302
Net income (gross income less expenses)	2014-12-31	$70,150
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$2,053,172
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$2,003,257
Assets. Value of participant loans	2014-12-31	$10,947
Assets. Value of assets in partnership/joint-venture interests	2014-12-31	$35,073
Expenses. Administrative service providers (salaries,fees and commissions)	2014-12-31	$4,576
2013 : JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2013 401k financial data
Transfers to/from the plan	2013-12-31	$92,015
Total income from all sources	2013-12-31	$89,265
Expenses. Total of all expenses incurred	2013-12-31	$2,973
Total plan assets at end of year	2013-12-31	$2,003,257
Total plan assets at beginning of year	2013-12-31	$1,824,950
Value of fidelity bond covering the plan	2013-12-31	$350,000
Total contributions received or receivable from participants	2013-12-31	$19,879
Other income received	2013-12-31	$33,515
Net income (gross income less expenses)	2013-12-31	$86,292
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$2,003,257
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$1,824,950
Assets. Value of participant loans	2013-12-31	$41,183
Assets. Value of assets in partnership/joint-venture interests	2013-12-31	$27,520
Total contributions received or receivable from employer(s)	2013-12-31	$35,871
Expenses. Administrative service providers (salaries,fees and commissions)	2013-12-31	$2,973
2012 : JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2012 401k financial data
Total income from all sources	2012-12-31	$264,959
Expenses. Total of all expenses incurred	2012-12-31	$1,070,232
Benefits paid (including direct rollovers)	2012-12-31	$1,070,232
Total plan assets at end of year	2012-12-31	$1,860,061
Total plan assets at beginning of year	2012-12-31	$2,665,334
Value of fidelity bond covering the plan	2012-12-31	$350,000
Total contributions received or receivable from participants	2012-12-31	$34,922
Other income received	2012-12-31	$181,484
Net income (gross income less expenses)	2012-12-31	$-805,273
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$1,860,061
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$2,665,334
Assets. Value of participant loans	2012-12-31	$80,169
Assets. Value of assets in partnership/joint-venture interests	2012-12-31	$77,536
Total contributions received or receivable from employer(s)	2012-12-31	$48,553
2011 : JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2011 401k financial data
Total income from all sources	2011-12-31	$99,443
Expenses. Total of all expenses incurred	2011-12-31	$970,522
Benefits paid (including direct rollovers)	2011-12-31	$970,522
Total plan assets at end of year	2011-12-31	$2,665,334
Total plan assets at beginning of year	2011-12-31	$3,536,413
Value of fidelity bond covering the plan	2011-12-31	$350,000
Total contributions received or receivable from participants	2011-12-31	$16,438
Other income received	2011-12-31	$53,618
Net income (gross income less expenses)	2011-12-31	$-871,079
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$2,665,334
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$3,536,413
Assets. Value of participant loans	2011-12-31	$45,059
Assets. Value of assets in partnership/joint-venture interests	2011-12-31	$92,110
Total contributions received or receivable from employer(s)	2011-12-31	$29,387
2010 : JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2010 401k financial data
Total income from all sources	2010-12-31	$755,267
Expenses. Total of all expenses incurred	2010-12-31	$639,763
Benefits paid (including direct rollovers)	2010-12-31	$639,763
Total plan assets at end of year	2010-12-31	$3,536,413
Total plan assets at beginning of year	2010-12-31	$3,420,909
Value of fidelity bond covering the plan	2010-12-31	$350,000
Total contributions received or receivable from participants	2010-12-31	$66,944
Other income received	2010-12-31	$534,969
Net income (gross income less expenses)	2010-12-31	$115,504
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$3,536,413
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$3,420,909
Assets. Value of participant loans	2010-12-31	$47,510
Assets. Value of assets in partnership/joint-venture interests	2010-12-31	$67,522
Total contributions received or receivable from employer(s)	2010-12-31	$153,354
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$581,009

Form 5500 Responses for JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN

2014: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
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 funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT 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 – Trust	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2010: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: JEFFERSON-SHELBY SURGICAL AFFILIATES PC 401 K RETIREMENT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

14812

Policy instance

Insurance contract or identification number	14812
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	Yes
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

14812

Policy instance

Insurance contract or identification number	14812
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	Yes
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	JEFFERSON-SHELBY SURGICAL AFFILIATES PC
Employer identification number (EIN):	630967549
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)