401k Plan data: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN plan

DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 401k Plan overview

Plan Name	DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN
Plan identification number	002

DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

DOUGLAS M. ANDERSON, DDS MS PC has sponsored the creation of one or more 401k plans.

Company Name: DOUGLAS M. ANDERSON, DDS MS PC

Employer identification number (EIN): 870676739

NAIC Classification: 621210
NAIC Description: Offices of Dentists

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2019-01-01
002 2018-01-01 DOUGLAS M. ANDERSON
002 2017-01-01 DOUGLAS M. ANDERSON
002 2016-01-01 DOUGLAS M. ANDERSON
002 2015-01-01 DOUGLAS M. ANDERSON
002 2014-01-01 DOUGLAS M. ANDERSON
002 2013-01-01 DOUGLAS M. ANDERSON
002 2012-01-01 DOUGLAS M. ANDERSON
002 2011-01-01 DOUGLAS M. ANDERSON
002 2010-01-01 DOUGLAS M. ANDERSON DOUGLAS M. ANDERSON 2011-09-28
002 2009-01-01 DOUGLAS M. ANDERSON DOUGLAS M. ANDERSON 2010-07-14
002 2009-01-01 DOUGLAS M. ANDERSON DOUGLAS M. ANDERSON 2011-09-28

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
002	2019-01-01
002	2018-01-01	DOUGLAS M. ANDERSON
002	2017-01-01	DOUGLAS M. ANDERSON
002	2016-01-01	DOUGLAS M. ANDERSON
002	2015-01-01	DOUGLAS M. ANDERSON
002	2014-01-01	DOUGLAS M. ANDERSON
002	2013-01-01	DOUGLAS M. ANDERSON
002	2012-01-01	DOUGLAS M. ANDERSON
002	2011-01-01	DOUGLAS M. ANDERSON
002	2010-01-01	DOUGLAS M. ANDERSON	DOUGLAS M. ANDERSON	2011-09-28
002	2009-01-01	DOUGLAS M. ANDERSON	DOUGLAS M. ANDERSON	2010-07-14
002	2009-01-01	DOUGLAS M. ANDERSON	DOUGLAS M. ANDERSON	2011-09-28

Plan Statistics for DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN

401k plan membership statisitcs for DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN

Measure Date Value
2019: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 3
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 0
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 0
Number of participants with account balances 2019-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 0
2018: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 9
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 2
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 1
Total of all active and inactive participants 2018-01-01 3
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 3
Number of participants with account balances 2018-01-01 3
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 0
2017: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 9
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 2
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 7
Total of all active and inactive participants 2017-01-01 9
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 9
Number of participants with account balances 2017-01-01 9
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 4
2016: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 8
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 7
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 1
Total of all active and inactive participants 2016-01-01 8
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 8
Number of participants with account balances 2016-01-01 8
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0
2015: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 7
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 8
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 8
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 8
Number of participants with account balances 2015-01-01 8
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 0
2014: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 6
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 6
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 1
Total of all active and inactive participants 2014-01-01 7
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 7
Number of participants with account balances 2014-01-01 7
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 2
2013: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING 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 6
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 6
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 6
Number of participants with account balances 2013-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 1
2012: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING 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 6
Number of retired or separated participants receiving benefits 2012-01-01 2
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
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 10
Number of participants with account balances 2012-01-01 10
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 1
2011: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING 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 9
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 1
Total of all active and inactive participants 2011-01-01 10
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 10
Number of participants with account balances 2011-01-01 10
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0
2010: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 11
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 9
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 1
Total of all active and inactive participants 2010-01-01 10
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
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 1
2009: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING 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 retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 9
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 9
Number of participants with account balances 2009-01-01 8
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2019: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	3
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	0
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	0
Number of participants with account balances	2019-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	0
2018: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	9
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	2
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	1
Total of all active and inactive participants	2018-01-01	3
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	3
Number of participants with account balances	2018-01-01	3
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	0
2017: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	9
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	2
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	7
Total of all active and inactive participants	2017-01-01	9
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	9
Number of participants with account balances	2017-01-01	9
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	4
2016: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	8
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	7
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	1
Total of all active and inactive participants	2016-01-01	8
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	8
Number of participants with account balances	2016-01-01	8
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0
2015: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	7
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	8
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	8
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	8
Number of participants with account balances	2015-01-01	8
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	0
2014: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	6
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	6
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	1
Total of all active and inactive participants	2014-01-01	7
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	7
Number of participants with account balances	2014-01-01	7
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	2
2013: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING 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	6
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	6
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	6
Number of participants with account balances	2013-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	1
2012: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING 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	6
Number of retired or separated participants receiving benefits	2012-01-01	2
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
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	10
Number of participants with account balances	2012-01-01	10
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	1
2011: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING 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	9
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	1
Total of all active and inactive participants	2011-01-01	10
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	10
Number of participants with account balances	2011-01-01	10
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2010: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	11
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	9
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	1
Total of all active and inactive participants	2010-01-01	10
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
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	1
2009: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING 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 retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	9
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	9
Number of participants with account balances	2009-01-01	8
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN

Measure	Date	Value
2019 : DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2019 401k financial data
Total plan liabilities at end of year	2019-12-31	$0
Total plan liabilities at beginning of year	2019-12-31	$0
Total income from all sources	2019-12-31	$182,126
Expenses. Total of all expenses incurred	2019-12-31	$2,002,330
Benefits paid (including direct rollovers)	2019-12-31	$2,002,330
Total plan assets at end of year	2019-12-31	$0
Total plan assets at beginning of year	2019-12-31	$1,820,204
Value of fidelity bond covering the plan	2019-12-31	$60,000
Total contributions received or receivable from participants	2019-12-31	$0
Expenses. Other expenses not covered elsewhere	2019-12-31	$0
Contributions received from other sources (not participants or employers)	2019-12-31	$0
Other income received	2019-12-31	$182,126
Noncash contributions received	2019-12-31	$0
Net income (gross income less expenses)	2019-12-31	$-1,820,204
Net plan assets at end of year (total assets less liabilities)	2019-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2019-12-31	$1,820,204
Total contributions received or receivable from employer(s)	2019-12-31	$0
Value of certain deemed distributions of participant loans	2019-12-31	$0
Value of corrective distributions	2019-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2019-12-31	$0
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-12-31	$0
2018 : DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2018 401k financial data
Total plan liabilities at end of year	2018-12-31	$0
Total plan liabilities at beginning of year	2018-12-31	$0
Total income from all sources	2018-12-31	$-115
Expenses. Total of all expenses incurred	2018-12-31	$31,962
Benefits paid (including direct rollovers)	2018-12-31	$28,830
Total plan assets at end of year	2018-12-31	$1,820,204
Total plan assets at beginning of year	2018-12-31	$1,852,281
Value of fidelity bond covering the plan	2018-12-31	$60,000
Total contributions received or receivable from participants	2018-12-31	$0
Expenses. Other expenses not covered elsewhere	2018-12-31	$0
Contributions received from other sources (not participants or employers)	2018-12-31	$0
Other income received	2018-12-31	$-115
Noncash contributions received	2018-12-31	$0
Net income (gross income less expenses)	2018-12-31	$-32,077
Net plan assets at end of year (total assets less liabilities)	2018-12-31	$1,820,204
Net plan assets at beginning of year (total assets less liabilities)	2018-12-31	$1,852,281
Total contributions received or receivable from employer(s)	2018-12-31	$0
Value of certain deemed distributions of participant loans	2018-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2018-12-31	$3,132
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-12-31	$0
2017 : DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2017 401k financial data
Total plan liabilities at end of year	2017-12-31	$0
Total plan liabilities at beginning of year	2017-12-31	$0
Total income from all sources	2017-12-31	$256,474
Expenses. Total of all expenses incurred	2017-12-31	$18,608
Benefits paid (including direct rollovers)	2017-12-31	$0
Total plan assets at end of year	2017-12-31	$1,852,281
Total plan assets at beginning of year	2017-12-31	$1,614,415
Value of fidelity bond covering the plan	2017-12-31	$60,000
Total contributions received or receivable from participants	2017-12-31	$51,314
Expenses. Other expenses not covered elsewhere	2017-12-31	$0
Contributions received from other sources (not participants or employers)	2017-12-31	$0
Other income received	2017-12-31	$194,446
Noncash contributions received	2017-12-31	$0
Net income (gross income less expenses)	2017-12-31	$237,866
Net plan assets at end of year (total assets less liabilities)	2017-12-31	$1,852,281
Net plan assets at beginning of year (total assets less liabilities)	2017-12-31	$1,614,415
Total contributions received or receivable from employer(s)	2017-12-31	$10,714
Value of certain deemed distributions of participant loans	2017-12-31	$0
Value of corrective distributions	2017-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2017-12-31	$18,608
2016 : DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2016 401k financial data
Total plan liabilities at end of year	2016-12-31	$0
Total plan liabilities at beginning of year	2016-12-31	$0
Total income from all sources	2016-12-31	$169,854
Expenses. Total of all expenses incurred	2016-12-31	$16,097
Benefits paid (including direct rollovers)	2016-12-31	$0
Total plan assets at end of year	2016-12-31	$1,614,415
Total plan assets at beginning of year	2016-12-31	$1,460,658
Value of fidelity bond covering the plan	2016-12-31	$60,000
Total contributions received or receivable from participants	2016-12-31	$51,812
Expenses. Other expenses not covered elsewhere	2016-12-31	$0
Contributions received from other sources (not participants or employers)	2016-12-31	$0
Other income received	2016-12-31	$107,637
Noncash contributions received	2016-12-31	$0
Net income (gross income less expenses)	2016-12-31	$153,757
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$1,614,415
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$1,460,658
Total contributions received or receivable from employer(s)	2016-12-31	$10,405
Value of certain deemed distributions of participant loans	2016-12-31	$0
Value of corrective distributions	2016-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2016-12-31	$16,097
2015 : DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2015 401k financial data
Transfers to/from the plan	2015-12-31	$0
Total plan liabilities at end of year	2015-12-31	$0
Total plan liabilities at beginning of year	2015-12-31	$0
Total income from all sources	2015-12-31	$870
Expenses. Total of all expenses incurred	2015-12-31	$23,978
Benefits paid (including direct rollovers)	2015-12-31	$23,918
Total plan assets at end of year	2015-12-31	$1,460,658
Total plan assets at beginning of year	2015-12-31	$1,483,766
Value of fidelity bond covering the plan	2015-12-31	$60,000
Total contributions received or receivable from participants	2015-12-31	$54,090
Expenses. Other expenses not covered elsewhere	2015-12-31	$0
Contributions received from other sources (not participants or employers)	2015-12-31	$0
Other income received	2015-12-31	$-65,503
Noncash contributions received	2015-12-31	$0
Net income (gross income less expenses)	2015-12-31	$-23,108
Net plan assets at end of year (total assets less liabilities)	2015-12-31	$1,460,658
Net plan assets at beginning of year (total assets less liabilities)	2015-12-31	$1,483,766
Total contributions received or receivable from employer(s)	2015-12-31	$12,283
Value of certain deemed distributions of participant loans	2015-12-31	$0
Value of corrective distributions	2015-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2015-12-31	$60
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2015-12-31	$0
2014 : DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2014 401k financial data
Total plan liabilities at end of year	2014-12-31	$0
Total plan liabilities at beginning of year	2014-12-31	$0
Total income from all sources	2014-12-31	$149,686
Expenses. Total of all expenses incurred	2014-12-31	$5,472
Benefits paid (including direct rollovers)	2014-12-31	$891
Total plan assets at end of year	2014-12-31	$1,483,766
Total plan assets at beginning of year	2014-12-31	$1,339,552
Value of fidelity bond covering the plan	2014-12-31	$60,000
Total contributions received or receivable from participants	2014-12-31	$50,390
Expenses. Other expenses not covered elsewhere	2014-12-31	$0
Contributions received from other sources (not participants or employers)	2014-12-31	$0
Other income received	2014-12-31	$89,095
Noncash contributions received	2014-12-31	$0
Net income (gross income less expenses)	2014-12-31	$144,214
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$1,483,766
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$1,339,552
Total contributions received or receivable from employer(s)	2014-12-31	$10,201
Value of certain deemed distributions of participant loans	2014-12-31	$0
Value of corrective distributions	2014-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2014-12-31	$4,581
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
2013 : DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2013 401k financial data
Total plan liabilities at end of year	2013-12-31	$0
Total plan liabilities at beginning of year	2013-12-31	$0
Total income from all sources	2013-12-31	$253,392
Expenses. Total of all expenses incurred	2013-12-31	$71,942
Benefits paid (including direct rollovers)	2013-12-31	$63,201
Total plan assets at end of year	2013-12-31	$1,339,552
Total plan assets at beginning of year	2013-12-31	$1,158,102
Value of fidelity bond covering the plan	2013-12-31	$60,000
Total contributions received or receivable from participants	2013-12-31	$52,315
Expenses. Other expenses not covered elsewhere	2013-12-31	$0
Contributions received from other sources (not participants or employers)	2013-12-31	$0
Other income received	2013-12-31	$189,876
Noncash contributions received	2013-12-31	$0
Net income (gross income less expenses)	2013-12-31	$181,450
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$1,339,552
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$1,158,102
Total contributions received or receivable from employer(s)	2013-12-31	$11,201
Value of certain deemed distributions of participant loans	2013-12-31	$0
Value of corrective distributions	2013-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2013-12-31	$8,741
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
2012 : DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2012 401k financial data
Total plan liabilities at end of year	2012-12-31	$0
Total plan liabilities at beginning of year	2012-12-31	$0
Total income from all sources	2012-12-31	$106,388
Expenses. Total of all expenses incurred	2012-12-31	$10,582
Benefits paid (including direct rollovers)	2012-12-31	$10,402
Total plan assets at end of year	2012-12-31	$1,158,102
Total plan assets at beginning of year	2012-12-31	$1,062,296
Value of fidelity bond covering the plan	2012-12-31	$60,000
Total contributions received or receivable from participants	2012-12-31	$55,025
Expenses. Other expenses not covered elsewhere	2012-12-31	$0
Contributions received from other sources (not participants or employers)	2012-12-31	$0
Other income received	2012-12-31	$37,719
Noncash contributions received	2012-12-31	$0
Net income (gross income less expenses)	2012-12-31	$95,806
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$1,158,102
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$1,062,296
Total contributions received or receivable from employer(s)	2012-12-31	$13,644
Value of certain deemed distributions of participant loans	2012-12-31	$0
Value of corrective distributions	2012-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2012-12-31	$180
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
2011 : DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2011 401k financial data
Transfers to/from the plan	2011-12-31	$0
Total plan liabilities at beginning of year	2011-12-31	$0
Total income from all sources	2011-12-31	$49,598
Expenses. Total of all expenses incurred	2011-12-31	$7,829
Benefits paid (including direct rollovers)	2011-12-31	$0
Total plan assets at end of year	2011-12-31	$1,062,296
Total plan assets at beginning of year	2011-12-31	$1,020,527
Value of fidelity bond covering the plan	2011-12-31	$60,000
Total contributions received or receivable from participants	2011-12-31	$54,403
Expenses. Other expenses not covered elsewhere	2011-12-31	$0
Contributions received from other sources (not participants or employers)	2011-12-31	$0
Other income received	2011-12-31	$-42,848
Noncash contributions received	2011-12-31	$0
Net income (gross income less expenses)	2011-12-31	$41,769
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$1,062,296
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$1,020,527
Total contributions received or receivable from employer(s)	2011-12-31	$38,043
Value of certain deemed distributions of participant loans	2011-12-31	$0
Value of corrective distributions	2011-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2011-12-31	$7,829
2010 : DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2010 401k financial data
Transfers to/from the plan	2010-12-31	$0
Total plan liabilities at end of year	2010-12-31	$0
Total plan liabilities at beginning of year	2010-12-31	$0
Total income from all sources	2010-12-31	$130,082
Expenses. Total of all expenses incurred	2010-12-31	$6,556
Benefits paid (including direct rollovers)	2010-12-31	$4,920
Total plan assets at end of year	2010-12-31	$1,020,527
Total plan assets at beginning of year	2010-12-31	$897,001
Value of fidelity bond covering the plan	2010-12-31	$60,000
Total contributions received or receivable from participants	2010-12-31	$48,933
Expenses. Other expenses not covered elsewhere	2010-12-31	$0
Contributions received from other sources (not participants or employers)	2010-12-31	$0
Other income received	2010-12-31	$37,144
Noncash contributions received	2010-12-31	$0
Net income (gross income less expenses)	2010-12-31	$123,526
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$1,020,527
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$897,001
Total contributions received or receivable from employer(s)	2010-12-31	$44,005
Value of certain deemed distributions of participant loans	2010-12-31	$0
Value of corrective distributions	2010-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2010-12-31	$1,636
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
2009 : DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2009 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2009-12-31	$0

Form 5500 Responses for DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN

2019: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	Yes
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING 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 funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING 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 funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING 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 funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2010: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: DOUGLAS M. ANDERSON, DDS, MS, PC PROFIT SHARING PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

ING USA ANNUITY AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1239918-OW

Policy instance

Insurance contract or identification number	1239918-OW
Number of Individuals Covered	0
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Are there contracts with allocated funds for individual policies?	0
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?	Yes
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

ING USA ANNUITY AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1239918-OW

Policy instance

Insurance contract or identification number	1239918-OW
Number of Individuals Covered	3
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Are there contracts with allocated funds for individual policies?	0
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?	Yes
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

ING USA ANNUITY AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1239918-OW

Policy instance

Insurance contract or identification number	1239918-OW
Number of Individuals Covered	9
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Are there contracts with allocated funds for individual policies?	0
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?	Yes
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

ING USA ANNUITY AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1239918-OW

Policy instance

Insurance contract or identification number	1239918-OW
Number of Individuals Covered	8
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
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?	Yes
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

ING USA ANNUITY AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1239918-OW

Policy instance

Insurance contract or identification number	1239918-OW
Number of Individuals Covered	7
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
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?	Yes
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

ING USA ANNUITY AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1239918-OW

Policy instance

Insurance contract or identification number	1239918-OW
Number of Individuals Covered	6
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
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?	Yes
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

ING USA ANNUITY AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1239918-OW

Policy instance

Insurance contract or identification number	1239918-OW
Number of Individuals Covered	10
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
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?	Yes
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

ING USA ANNUITY AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1239918-OW

Policy instance

Insurance contract or identification number	1239918-OW
Number of Individuals Covered	10
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
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?	Yes
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	DOUGLAS M. ANDERSON, DDS MS PC
Employer identification number (EIN):	870676739
NAIC Classification:	621210
NAIC Description:	Offices of Dentists