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AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN 401k Plan overview

Plan NameAMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN
Plan identification number 501

AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES has sponsored the creation of one or more 401k plans.

Company Name:AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES
Employer identification number (EIN):680561704
NAIC Classification:621491
NAIC Description:HMO Medical Centers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012020-01-01JENNIFER RIVA-KIRK2021-07-30 JENNIFER RIVA-KIRK2021-07-30
5012019-01-01
5012018-01-01JENNIFER RIVA-KIRK2019-07-08 JENNIFER RIVA-KIRK2019-07-08
5012017-01-01JENNIFER RIVA-KIRK2018-07-30 JENNIFER RIVA-KIRK2018-07-30
5012016-01-01JENNIFER RIVA-KIRK2017-10-09 JENNIFER RIVA-KIRK2017-10-09
5012015-01-01DERRICK QUAN DERRICK QUAN2016-10-17
5012014-01-01JOHN KUVEIKIS
5012013-01-01ANNA DYKSHTEYN

Plan Statistics for AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN

401k plan membership statisitcs for AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN

Measure Date Value
2015: AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01144
Total of all active and inactive participants2015-01-010
2014: AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01162
Total number of active participants reported on line 7a of the Form 55002014-01-01144
Total of all active and inactive participants2014-01-01144
2013: AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01110
Total number of active participants reported on line 7a of the Form 55002013-01-01162
Total of all active and inactive participants2013-01-01162

Financial Data on AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN

Measure Date Value
2015 : AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN 2015 401k financial data
Total unrealized appreciation/depreciation of assets2015-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2015-12-31$38,286
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2015-12-31$179,976
Total income from all sources (including contributions)2015-12-31$125,036
Total loss/gain on sale of assets2015-12-31$0
Total of all expenses incurred2015-12-31$29,527
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2015-12-31$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)2015-12-31$0
Value of total assets at end of year2015-12-31$100,032
Value of total assets at beginning of year2015-12-31$146,213
Total of administrative expenses incurred including professional, contract, advisory and management fees2015-12-31$29,527
Total interest from all sources2015-12-31$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 year2015-12-31Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan2015-12-31$0
Administrative expenses professional fees incurred2015-12-31$15,320
Was this plan covered by a fidelity bond2015-12-31Yes
Value of fidelity bond cover2015-12-31$40,000
If this is an individual account plan, was there a blackout period2015-12-31No
Were there any nonexempt tranactions with any party-in-interest2015-12-31No
Other income not declared elsewhere2015-12-31$125,036
Administrative expenses (other) incurred2015-12-31$4,785
Liabilities. Value of operating payables at end of year2015-12-31$38,286
Liabilities. Value of operating payables at beginning of year2015-12-31$32,725
Total non interest bearing cash at end of year2015-12-31$100,032
Total non interest bearing cash at beginning of year2015-12-31$146,213
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2015-12-31No
Value of net income/loss2015-12-31$95,509
Value of net assets at end of year (total assets less liabilities)2015-12-31$61,746
Value of net assets at beginning of year (total assets less liabilities)2015-12-31$-33,763
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2015-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2015-12-31No
Were any leases to which the plan was party in default or uncollectible2015-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2015-12-31No
Was there a failure to transmit to the plan any participant contributions2015-12-31No
Has the plan failed to provide any benefit when due under the plan2015-12-31No
Contract administrator fees2015-12-31$9,422
Liabilities. Value of benefit claims payable at end of year2015-12-31$0
Liabilities. Value of benefit claims payable at beginning of year2015-12-31$147,251
Did the plan have assets held for investment2015-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2015-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2015-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2015-12-31No
Opinion of an independent qualified public accountant for this plan2015-12-31Unqualified
Accountancy firm name2015-12-31INEICH & COMPANY, LLP
Accountancy firm EIN2015-12-31562552172
2014 : AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN 2014 401k financial data
Total unrealized appreciation/depreciation of assets2014-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2014-12-31$179,976
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2014-12-31$116,766
Total income from all sources (including contributions)2014-12-31$133,098
Total loss/gain on sale of assets2014-12-31$0
Total of all expenses incurred2014-12-31$213,772
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2014-12-31$127,538
Total contributions o plan (from employers,participants, others, non cash contrinutions)2014-12-31$133,098
Value of total assets at end of year2014-12-31$146,213
Value of total assets at beginning of year2014-12-31$163,677
Total of administrative expenses incurred including professional, contract, advisory and management fees2014-12-31$86,234
Total interest from all sources2014-12-31$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 year2014-12-31Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan2014-12-31$0
Administrative expenses professional fees incurred2014-12-31$23,184
Was this plan covered by a fidelity bond2014-12-31Yes
Value of fidelity bond cover2014-12-31$40,000
If this is an individual account plan, was there a blackout period2014-12-31No
Were there any nonexempt tranactions with any party-in-interest2014-12-31No
Administrative expenses (other) incurred2014-12-31$26,023
Liabilities. Value of operating payables at end of year2014-12-31$32,725
Liabilities. Value of operating payables at beginning of year2014-12-31$18,647
Total non interest bearing cash at end of year2014-12-31$146,213
Total non interest bearing cash at beginning of year2014-12-31$139,130
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2014-12-31No
Value of net income/loss2014-12-31$-80,674
Value of net assets at end of year (total assets less liabilities)2014-12-31$-33,763
Value of net assets at beginning of year (total assets less liabilities)2014-12-31$46,911
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2014-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2014-12-31No
Were any leases to which the plan was party in default or uncollectible2014-12-31No
Expenses. Payments to insurance carriers foe the provision of benefits2014-12-31$22,230
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2014-12-31No
Was there a failure to transmit to the plan any participant contributions2014-12-31No
Has the plan failed to provide any benefit when due under the plan2014-12-31No
Contributions received in cash from employer2014-12-31$133,098
Employer contributions (assets) at beginning of year2014-12-31$24,547
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2014-12-31$105,308
Contract administrator fees2014-12-31$37,027
Liabilities. Value of benefit claims payable at end of year2014-12-31$147,251
Liabilities. Value of benefit claims payable at beginning of year2014-12-31$98,119
Did the plan have assets held for investment2014-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2014-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2014-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2014-12-31No
Opinion of an independent qualified public accountant for this plan2014-12-31Unqualified
Accountancy firm name2014-12-31INEICH & COMPANY, LLP
Accountancy firm EIN2014-12-31562552172
2013 : AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN 2013 401k financial data
Total unrealized appreciation/depreciation of assets2013-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2013-12-31$116,766
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2013-12-31$0
Total income from all sources (including contributions)2013-12-31$305,833
Total loss/gain on sale of assets2013-12-31$0
Total of all expenses incurred2013-12-31$258,922
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2013-12-31$162,314
Total contributions o plan (from employers,participants, others, non cash contrinutions)2013-12-31$305,833
Value of total assets at end of year2013-12-31$163,677
Value of total assets at beginning of year2013-12-31$0
Total of administrative expenses incurred including professional, contract, advisory and management fees2013-12-31$96,608
Total interest from all sources2013-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2013-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2013-12-31No
Administrative expenses professional fees incurred2013-12-31$214
Was this plan covered by a fidelity bond2013-12-31Yes
Value of fidelity bond cover2013-12-31$40,000
If this is an individual account plan, was there a blackout period2013-12-31No
Were there any nonexempt tranactions with any party-in-interest2013-12-31No
Administrative expenses (other) incurred2013-12-31$44,402
Liabilities. Value of operating payables at end of year2013-12-31$18,647
Total non interest bearing cash at end of year2013-12-31$139,130
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2013-12-31No
Value of net income/loss2013-12-31$46,911
Value of net assets at end of year (total assets less liabilities)2013-12-31$46,911
Value of net assets at beginning of year (total assets less liabilities)2013-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2013-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2013-12-31No
Were any leases to which the plan was party in default or uncollectible2013-12-31No
Expenses. Payments to insurance carriers foe the provision of benefits2013-12-31$52,334
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2013-12-31No
Was there a failure to transmit to the plan any participant contributions2013-12-31No
Has the plan failed to provide any benefit when due under the plan2013-12-31No
Contributions received in cash from employer2013-12-31$305,833
Employer contributions (assets) at end of year2013-12-31$24,547
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2013-12-31$109,980
Contract administrator fees2013-12-31$51,992
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32013-12-31No
Liabilities. Value of benefit claims payable at end of year2013-12-31$98,119
Did the plan have assets held for investment2013-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2013-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2013-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2013-12-31No
Opinion of an independent qualified public accountant for this plan2013-12-31Unqualified
Accountancy firm name2013-12-31INEICH & COMPANY, LLP
Accountancy firm EIN2013-12-31562552172

Form 5500 Responses for AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN

2015: AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – TrustYes
2015-01-01Plan benefit arrangement - TrustYes
2014: AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – TrustYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement - TrustYes
2013: AMERICAN CHORE SERVICES, INC. DBA CITY CHOICE HOME CARE SERVICES HEALTH & WELFARE PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01First time form 5500 has been submittedYes
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – TrustYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract numberSSL DENT CIHC 1
Policy instance 1
Insurance contract or identification numberSSL DENT CIHC 1
Number of Individuals Covered153
Insurance policy start date2013-12-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $34,746
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number656
Policy instance 2
Insurance contract or identification number656
Number of Individuals Covered146
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberVAR 645896
Policy instance 1
Insurance contract or identification numberVAR 645896
Number of Individuals Covered161
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $229
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees229
Additional information about fees paid to insurance brokerADMINISTRATIVE & OTHER SERIVES
Insurance broker organization code?5
Insurance broker nameFCE BENEFIT ADMINISTRATORS, INC.
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 645896
Policy instance 2
Insurance contract or identification numberGL 645896
Number of Individuals Covered161
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,065
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees1065
Additional information about fees paid to insurance brokerADMINISTRATIVE & OTHER SERIVES
Insurance broker organization code?5
Insurance broker nameFCE BENEFIT ADMINISTRATORS, INC.
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract numberSSLDENTCIHC01
Policy instance 3
Insurance contract or identification numberSSLDENTCIHC01
Number of Individuals Covered135
Insurance policy start date2012-12-01
Insurance policy end date2013-11-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $34,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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