401k Plan data: S.R. BURZYNSKI 401(K) PLAN plan

S.R. BURZYNSKI 401(K) PLAN 401k Plan overview

Plan Name	S.R. BURZYNSKI 401(K) PLAN
Plan identification number	001

S.R. BURZYNSKI 401(K) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Plan provides for automatic enrollment in plan that has employee contributions deducted from payroll.
Plan covering Self-Employed individuals.
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

S.R. BURZYNSKI, MD, PHD has sponsored the creation of one or more 401k plans.

Company Name: S.R. BURZYNSKI, MD, PHD

Employer identification number (EIN): 760301750

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan S.R. BURZYNSKI 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01 PATRYK GOSCIANSKI 2023-10-16
001 2021-01-01 PATRYK GOSCIANSKI 2022-10-04 PATRYK GOSCIANSKI 2022-10-04
001 2020-01-01 PATRYK GOSCIANSKI 2021-10-05 PATRYK GOSCIANSKI 2021-10-05
001 2019-01-01 PATRYK GOSCIANSKI 2020-10-08 PATRYK GOSCIANSKI 2020-10-08
001 2018-01-01 PATRYK GOSCIANSKI 2019-10-10 PATRYK GOSCIANSKI 2019-10-10
001 2017-01-01 PATRYK GOSCIANSKI 2018-10-10 PATRYK GOSCIANSKI 2018-10-10
001 2016-01-01 PATRYK GOSCIANSKI 2018-01-25 PATRYK GOSCIANSKI 2018-01-25
001 2015-01-01 PATRYK GOSCIANSKI
001 2015-01-01 PATRYK GOSCIANSKI
001 2014-01-01 PATRYK GOSCIANSKI
001 2013-01-01 PATRYK GOSCIANSKI
001 2012-01-01 PATRYK GOSCIANSKI
001 2011-01-01 PATRYK GOSCIANSKI
001 2009-01-01 BARBARA TOMASZEWSKI
001 2009-01-01 BARBARA TOMASZEWSKI

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2022-01-01	PATRYK GOSCIANSKI	2023-10-16
001	2021-01-01	PATRYK GOSCIANSKI	2022-10-04	PATRYK GOSCIANSKI	2022-10-04
001	2020-01-01	PATRYK GOSCIANSKI	2021-10-05	PATRYK GOSCIANSKI	2021-10-05
001	2019-01-01	PATRYK GOSCIANSKI	2020-10-08	PATRYK GOSCIANSKI	2020-10-08
001	2018-01-01	PATRYK GOSCIANSKI	2019-10-10	PATRYK GOSCIANSKI	2019-10-10
001	2017-01-01	PATRYK GOSCIANSKI	2018-10-10	PATRYK GOSCIANSKI	2018-10-10
001	2016-01-01	PATRYK GOSCIANSKI	2018-01-25	PATRYK GOSCIANSKI	2018-01-25
001	2015-01-01	PATRYK GOSCIANSKI
001	2015-01-01	PATRYK GOSCIANSKI
001	2014-01-01	PATRYK GOSCIANSKI
001	2013-01-01	PATRYK GOSCIANSKI
001	2012-01-01	PATRYK GOSCIANSKI
001	2011-01-01	PATRYK GOSCIANSKI
001	2009-01-01	BARBARA TOMASZEWSKI
001	2009-01-01	BARBARA TOMASZEWSKI

Plan Statistics for S.R. BURZYNSKI 401(K) PLAN

401k plan membership statisitcs for S.R. BURZYNSKI 401(K) PLAN

Measure Date Value
2015: S.R. BURZYNSKI 401(K) PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 108
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 57
Number of retired or separated participants receiving benefits 2015-01-01 7
Number of other retired or separated participants entitled to future benefits 2015-01-01 27
Total of all active and inactive participants 2015-01-01 91
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 2
Total participants 2015-01-01 93
Number of participants with account balances 2015-01-01 64
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 1
2014: S.R. BURZYNSKI 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 130
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 70
Number of retired or separated participants receiving benefits 2014-01-01 6
Number of other retired or separated participants entitled to future benefits 2014-01-01 32
Total of all active and inactive participants 2014-01-01 108
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 1
Total participants 2014-01-01 109
Number of participants with account balances 2014-01-01 75
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 4
2013: S.R. BURZYNSKI 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 155
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 89
Number of retired or separated participants receiving benefits 2013-01-01 8
Number of other retired or separated participants entitled to future benefits 2013-01-01 31
Total of all active and inactive participants 2013-01-01 128
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 128
Number of participants with account balances 2013-01-01 82
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 5
2012: S.R. BURZYNSKI 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 146
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 125
Number of retired or separated participants receiving benefits 2012-01-01 7
Number of other retired or separated participants entitled to future benefits 2012-01-01 20
Total of all active and inactive participants 2012-01-01 152
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 1
Total participants 2012-01-01 153
Number of participants with account balances 2012-01-01 86
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: S.R. BURZYNSKI 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 145
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 116
Number of retired or separated participants receiving benefits 2011-01-01 2
Number of other retired or separated participants entitled to future benefits 2011-01-01 21
Total of all active and inactive participants 2011-01-01 139
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 139
Number of participants with account balances 2011-01-01 79
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 2
2009: S.R. BURZYNSKI 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 123
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 93
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 21
Total of all active and inactive participants 2009-01-01 114
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 114
Number of participants with account balances 2009-01-01 77
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 1

Measure	Date	Value
2015: S.R. BURZYNSKI 401(K) PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	108
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	57
Number of retired or separated participants receiving benefits	2015-01-01	7
Number of other retired or separated participants entitled to future benefits	2015-01-01	27
Total of all active and inactive participants	2015-01-01	91
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	2
Total participants	2015-01-01	93
Number of participants with account balances	2015-01-01	64
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	1
2014: S.R. BURZYNSKI 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	130
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	70
Number of retired or separated participants receiving benefits	2014-01-01	6
Number of other retired or separated participants entitled to future benefits	2014-01-01	32
Total of all active and inactive participants	2014-01-01	108
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	1
Total participants	2014-01-01	109
Number of participants with account balances	2014-01-01	75
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	4
2013: S.R. BURZYNSKI 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	155
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	89
Number of retired or separated participants receiving benefits	2013-01-01	8
Number of other retired or separated participants entitled to future benefits	2013-01-01	31
Total of all active and inactive participants	2013-01-01	128
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	128
Number of participants with account balances	2013-01-01	82
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	5
2012: S.R. BURZYNSKI 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	146
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	125
Number of retired or separated participants receiving benefits	2012-01-01	7
Number of other retired or separated participants entitled to future benefits	2012-01-01	20
Total of all active and inactive participants	2012-01-01	152
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	1
Total participants	2012-01-01	153
Number of participants with account balances	2012-01-01	86
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: S.R. BURZYNSKI 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	145
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	116
Number of retired or separated participants receiving benefits	2011-01-01	2
Number of other retired or separated participants entitled to future benefits	2011-01-01	21
Total of all active and inactive participants	2011-01-01	139
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	139
Number of participants with account balances	2011-01-01	79
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	2
2009: S.R. BURZYNSKI 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	93
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	21
Total of all active and inactive participants	2009-01-01	114
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	114
Number of participants with account balances	2009-01-01	77
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	1

Financial Data on S.R. BURZYNSKI 401(K) PLAN

Measure	Date	Value
2015 : S.R. BURZYNSKI 401(K) PLAN 2015 401k financial data
Total unrealized appreciation/depreciation of assets	2015-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$9,518
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total income from all sources (including contributions)	2015-12-31	$147,181
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$1,527,033
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$1,515,795
Value of total corrective distributions	2015-12-31	$9,518
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$224,284
Value of total assets at end of year	2015-12-31	$2,871,798
Value of total assets at beginning of year	2015-12-31	$4,242,132
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$1,720
Total interest from all sources	2015-12-31	$25,537
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2015-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$214,352
Participant contributions at end of year	2015-12-31	$13,141
Participant contributions at beginning of year	2015-12-31	$41,602
Participant contributions at beginning of year	2015-12-31	$660
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2015-12-31	$9,518
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Value of net income/loss	2015-12-31	$-1,379,852
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$2,862,280
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$4,242,132
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-12-31	No
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2015-12-31	$1,989,658
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2015-12-31	$2,351,082
Interest on participant loans	2015-12-31	$1,182
Interest earned on other investments	2015-12-31	$24,355
Value of interest in common/collective trusts at end of year	2015-12-31	$19,448
Value of interest in common/collective trusts at beginning of year	2015-12-31	$16,943
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2015-12-31	$849,551
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2015-12-31	$1,831,808
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2015-12-31	$-102,640
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-12-31	No
Was there a failure to transmit to the plan any participant contributions	2015-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Contributions received in cash from employer	2015-12-31	$9,932
Employer contributions (assets) at beginning of year	2015-12-31	$37
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$1,515,795
Contract administrator fees	2015-12-31	$1,720
Did the plan have assets held for investment	2015-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2015-12-31	Disclaimer
Accountancy firm name	2015-12-31	SEITZ, DEMARCO& MCGOVERN, PLLC
Accountancy firm EIN	2015-12-31	461149388
2014 : S.R. BURZYNSKI 401(K) PLAN 2014 401k financial data
Total unrealized appreciation/depreciation of assets	2014-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$7,835
Total income from all sources (including contributions)	2014-12-31	$465,610
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$489,218
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$461,570
Expenses. Certain deemed distributions of participant loans	2014-12-31	$26,326
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$270,928
Value of total assets at end of year	2014-12-31	$4,242,132
Value of total assets at beginning of year	2014-12-31	$4,273,575
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$1,322
Total interest from all sources	2014-12-31	$29,523
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2014-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$259,413
Participant contributions at end of year	2014-12-31	$41,602
Participant contributions at beginning of year	2014-12-31	$66,343
Participant contributions at end of year	2014-12-31	$660
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Value of net income/loss	2014-12-31	$-23,608
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$4,242,132
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$4,265,740
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-12-31	No
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2014-12-31	$2,351,082
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2014-12-31	$2,468,049
Interest on participant loans	2014-12-31	$1,382
Interest earned on other investments	2014-12-31	$28,141
Value of interest in common/collective trusts at end of year	2014-12-31	$16,943
Value of interest in common/collective trusts at beginning of year	2014-12-31	$29,230
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-12-31	$1,831,808
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-12-31	$1,709,953
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2014-12-31	$165,159
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-12-31	No
Was there a failure to transmit to the plan any participant contributions	2014-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Contributions received in cash from employer	2014-12-31	$11,515
Employer contributions (assets) at end of year	2014-12-31	$37
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$461,570
Contract administrator fees	2014-12-31	$1,322
Liabilities. Value of benefit claims payable at beginning of year	2014-12-31	$7,835
Did the plan have assets held for investment	2014-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2014-12-31	Disclaimer
Accountancy firm name	2014-12-31	SEITZ, DEMARCO & MCGOVERN, PLLC
Accountancy firm EIN	2014-12-31	461149388
2013 : S.R. BURZYNSKI 401(K) PLAN 2013 401k financial data
Total unrealized appreciation/depreciation of assets	2013-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$7,835
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$14,638
Total income from all sources (including contributions)	2013-12-31	$806,061
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$187,960
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$178,623
Value of total corrective distributions	2013-12-31	$7,835
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$403,296
Value of total assets at end of year	2013-12-31	$4,273,575
Value of total assets at beginning of year	2013-12-31	$3,662,277
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$1,502
Total interest from all sources	2013-12-31	$23,107
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 year	2013-12-31	No
Was this plan covered by a fidelity bond	2013-12-31	Yes
Value of fidelity bond cover	2013-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2013-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$379,061
Participant contributions at end of year	2013-12-31	$66,343
Participant contributions at beginning of year	2013-12-31	$47,315
Participant contributions at beginning of year	2013-12-31	$13,842
Income. Received or receivable in cash from other sources (including rollovers)	2013-12-31	$1,666
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Value of net income/loss	2013-12-31	$618,101
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$4,265,740
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$3,647,639
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-12-31	No
Were any leases to which the plan was party in default or uncollectible	2013-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2013-12-31	$2,468,049
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2013-12-31	$2,286,607
Interest on participant loans	2013-12-31	$1,289
Interest earned on other investments	2013-12-31	$21,818
Value of interest in common/collective trusts at end of year	2013-12-31	$29,230
Value of interest in common/collective trusts at beginning of year	2013-12-31	$12,046
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2013-12-31	$1,709,953
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2013-12-31	$1,302,046
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2013-12-31	$379,658
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	No
Was there a failure to transmit to the plan any participant contributions	2013-12-31	No
Has the plan failed to provide any benefit when due under the plan	2013-12-31	No
Contributions received in cash from employer	2013-12-31	$22,569
Employer contributions (assets) at beginning of year	2013-12-31	$421
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$178,623
Contract administrator fees	2013-12-31	$1,502
Liabilities. Value of benefit claims payable at end of year	2013-12-31	$7,835
Liabilities. Value of benefit claims payable at beginning of year	2013-12-31	$14,638
Did the plan have assets held for investment	2013-12-31	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	2013-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2013-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2013-12-31	Disclaimer
Accountancy firm name	2013-12-31	SEITZ, DEMARCO & MCGOVERN, PLLC
Accountancy firm EIN	2013-12-31	461149388
2012 : S.R. BURZYNSKI 401(K) PLAN 2012 401k financial data
Total unrealized appreciation/depreciation of assets	2012-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$14,638
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total income from all sources (including contributions)	2012-12-31	$732,230
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$265,816
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$249,860
Value of total corrective distributions	2012-12-31	$14,638
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$461,161
Value of total assets at end of year	2012-12-31	$3,662,277
Value of total assets at beginning of year	2012-12-31	$3,181,225
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$1,318
Total interest from all sources	2012-12-31	$12,688
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$440,705
Participant contributions at end of year	2012-12-31	$47,315
Participant contributions at beginning of year	2012-12-31	$35,958
Participant contributions at end of year	2012-12-31	$13,842
Income. Received or receivable in cash from other sources (including rollovers)	2012-12-31	$5,273
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	$466,414
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$3,647,639
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$3,181,225
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	$2,286,607
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2012-12-31	$1,918,038
Interest on participant loans	2012-12-31	$1,802
Interest earned on other investments	2012-12-31	$10,886
Value of interest in common/collective trusts at end of year	2012-12-31	$12,046
Value of interest in common/collective trusts at beginning of year	2012-12-31	$1,227,229
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$1,302,046
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2012-12-31	$255,671
Net investment gain or loss from common/collective trusts	2012-12-31	$2,710
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	$15,183
Employer contributions (assets) at end of year	2012-12-31	$421
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$249,860
Contract administrator fees	2012-12-31	$1,318
Liabilities. Value of benefit claims payable at end of year	2012-12-31	$14,638
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	SEITZ, DEMARCO & MCGOVERN, PLLC
Accountancy firm EIN	2012-12-31	461149388
2011 : S.R. BURZYNSKI 401(K) PLAN 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	$320,897
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$193,029
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$192,279
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$404,382
Value of total assets at end of year	2011-12-31	$3,181,225
Value of total assets at beginning of year	2011-12-31	$3,053,357
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$750
Total interest from all sources	2011-12-31	$2,474
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	$1,000,000
If this is an individual account plan, was there a blackout period	2011-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$389,707
Participant contributions at end of year	2011-12-31	$35,958
Participant contributions at beginning of year	2011-12-31	$51,170
Participant contributions at beginning of year	2011-12-31	$10,796
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	$127,868
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$3,181,225
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$3,053,357
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	$1,918,038
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2011-12-31	$1,975,976
Interest on participant loans	2011-12-31	$2,474
Value of interest in common/collective trusts at end of year	2011-12-31	$1,227,229
Value of interest in common/collective trusts at beginning of year	2011-12-31	$1,005,724
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2011-12-31	$-85,959
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	$14,675
Employer contributions (assets) at beginning of year	2011-12-31	$9,691
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$192,279
Contract administrator fees	2011-12-31	$750
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	SEITZ & DEMARCO, P.C.
Accountancy firm EIN	2011-12-31	760094964
2010 : S.R. BURZYNSKI 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	$640,277
Total loss/gain on sale of assets	2010-12-31	$0
Total of all expenses incurred	2010-12-31	$79,974
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$78,701
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$386,506
Value of total assets at end of year	2010-12-31	$3,053,357
Value of total assets at beginning of year	2010-12-31	$2,493,054
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$1,273
Total interest from all sources	2010-12-31	$3,269
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$100
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2010-12-31	$100
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$1,000,000
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	$362,781
Participant contributions at end of year	2010-12-31	$51,170
Participant contributions at beginning of year	2010-12-31	$59,761
Participant contributions at end of year	2010-12-31	$10,796
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	$560,303
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$3,053,357
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$2,493,054
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	$1,975,976
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2010-12-31	$1,599,584
Interest on participant loans	2010-12-31	$3,269
Value of interest in common/collective trusts at end of year	2010-12-31	$1,005,724
Value of interest in common/collective trusts at beginning of year	2010-12-31	$833,709
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2010-12-31	$250,402
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	$23,725
Employer contributions (assets) at end of year	2010-12-31	$9,691
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$78,701
Contract administrator fees	2010-12-31	$1,273
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	SEITZ & DEMARCO, P.C.
Accountancy firm EIN	2010-12-31	760094964

Form 5500 Responses for S.R. BURZYNSKI 401(K) PLAN

2015: S.R. BURZYNSKI 401(K) PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: S.R. BURZYNSKI 401(K) 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 – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: S.R. BURZYNSKI 401(K) 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: S.R. BURZYNSKI 401(K) PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	Yes
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 benefit arrangement – Insurance	Yes
2011: S.R. BURZYNSKI 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 benefit arrangement – Insurance	Yes
2009: S.R. BURZYNSKI 401(K) PLAN 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

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-029449

Policy instance

Insurance contract or identification number	GA-029449
Number of Individuals Covered	64
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $11,721
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	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,721
Insurance broker organization code?	3
Insurance broker name	PARK AVENUE SECURITIES, LLC

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-029449

Policy instance

Insurance contract or identification number	GA-029449
Number of Individuals Covered	75
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12,510
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	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,510
Insurance broker organization code?	3
Insurance broker name	PARK AVENUE SECURITIES, LLC

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-029449

Policy instance

Insurance contract or identification number	GA-029449
Number of Individuals Covered	82
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $11,438
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	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,438
Insurance broker organization code?	3
Insurance broker name	PARK AVENUE SECURITIES, LLC

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-029449

Policy instance

Insurance contract or identification number	GA-029449
Number of Individuals Covered	86
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $9,838
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	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,838
Insurance broker organization code?	3
Insurance broker name	PARK AVENUE SECURITIES, LLC

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-029449

Policy instance

Insurance contract or identification number	GA-029449
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $9,229
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	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-029449

Policy instance

Insurance contract or identification number	GA-029449
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 $7,633
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	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,633
Insurance broker organization code?	3
Insurance broker name	PARK AVENUE SECURITIES, LLC

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Company Name:	S.R. BURZYNSKI, MD, PHD
Employer identification number (EIN):	760301750
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)