401k Plan data: TAX DEFERRED ANNUITY PLAN OF HSA plan

TAX DEFERRED ANNUITY PLAN OF HSA 401k Plan overview

Plan Name	TAX DEFERRED ANNUITY PLAN OF HSA
Plan identification number	002

TAX DEFERRED ANNUITY PLAN OF HSA Benefits

401k Plan Type	Defined Contribution Pension
Plan Features/Benefits	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 403(b)(1) arrangement - See Limited Pension Plan Reporting instructions for Code section 403(b)(1) arrangements for certain exempt organizations.

401k Sponsoring company profile

HUMAN SERVICES ASSOCIATION has sponsored the creation of one or more 401k plans.

Company Name: HUMAN SERVICES ASSOCIATION

Employer identification number (EIN): 951816054

NAIC Classification: 813000
NAIC Description: Religious, Grantmaking, Civic, Professional, and Similar Organizations

Additional information about HUMAN SERVICES ASSOCIATION

Jurisdiction of Incorporation: California Department of State

Incorporation Date:

Company Identification Number: C0729827

More information about HUMAN SERVICES ASSOCIATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TAX DEFERRED ANNUITY PLAN OF HSA

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2015-01-01 RICARDO MOTA 2015-04-15 RICARDO MOTA 2015-04-15
002 2014-01-01 RICARDO MOTA 2015-04-15 RICARDO MOTA 2015-04-15
002 2013-01-01 RICARDO MOTA 2014-09-30 RICARDO MOTA 2014-09-30
002 2012-01-01 RICARDO MOTA 2014-09-30 RICARDO MOTA 2014-09-30
002 2011-01-01 RICARDO MOTA 2014-09-30 RICARDO MOTA 2014-09-30
002 2010-01-01 RICARDO MOTA 2014-09-30 RICARDO MOTA 2014-09-30
002 2009-01-01 RICARDO MOTA

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
002	2015-01-01	RICARDO MOTA	2015-04-15	RICARDO MOTA	2015-04-15
002	2014-01-01	RICARDO MOTA	2015-04-15	RICARDO MOTA	2015-04-15
002	2013-01-01	RICARDO MOTA	2014-09-30	RICARDO MOTA	2014-09-30
002	2012-01-01	RICARDO MOTA	2014-09-30	RICARDO MOTA	2014-09-30
002	2011-01-01	RICARDO MOTA	2014-09-30	RICARDO MOTA	2014-09-30
002	2010-01-01	RICARDO MOTA	2014-09-30	RICARDO MOTA	2014-09-30
002	2009-01-01	RICARDO MOTA

Plan Statistics for TAX DEFERRED ANNUITY PLAN OF HSA

401k plan membership statisitcs for TAX DEFERRED ANNUITY PLAN OF HSA

Measure Date Value
2009: TAX DEFERRED ANNUITY PLAN OF HSA 2009 401k membership
Total participants, beginning-of-year 2009-01-01 25
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 23
Number of retired or separated participants receiving benefits 2009-01-01 9
Total of all active and inactive participants 2009-01-01 32
Total participants 2009-01-01 32

Measure	Date	Value
2009: TAX DEFERRED ANNUITY PLAN OF HSA 2009 401k membership
Total participants, beginning-of-year	2009-01-01	25
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	23
Number of retired or separated participants receiving benefits	2009-01-01	9
Total of all active and inactive participants	2009-01-01	32
Total participants	2009-01-01	32

Financial Data on TAX DEFERRED ANNUITY PLAN OF HSA

Measure	Date	Value
2012 : TAX DEFERRED ANNUITY PLAN OF HSA 2012 401k financial data
Total income from all sources (including contributions)	2012-12-31	$16,766
Total of all expenses incurred	2012-12-31	$86,519
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$86,519
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$2,555
Value of total assets at end of year	2012-12-31	$124,637
Value of total assets at beginning of year	2012-12-31	$194,390
Total interest from all sources	2012-12-31	$14,211
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
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$2,555
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2012-12-31	$86,519
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	$-69,753
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$124,637
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$194,390
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	$62,889
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2012-12-31	$131,631
Value of interest in common/collective trusts at end of year	2012-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2012-12-31	$61,748
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2012-12-31	$62,759
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2012-12-31	$62,759
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2012-12-31	$14,211
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
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	No
Opinion of an independent qualified public accountant for this plan	2012-12-31	Unqualified
Accountancy firm name	2012-12-31	GERALD J. KASTNER, CPA
Accountancy firm EIN	2012-12-31	952402233
2011 : TAX DEFERRED ANNUITY PLAN OF HSA 2011 401k financial data
Total income from all sources (including contributions)	2011-12-31	$2,076
Total of all expenses incurred	2011-12-31	$2,982
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$2,982
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$1,500
Value of total assets at end of year	2011-12-31	$194,390
Value of total assets at beginning of year	2011-12-31	$195,296
Total interest from all sources	2011-12-31	$576
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
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$1,500
Participant contributions at beginning of year	2011-12-31	$357
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2011-12-31	$2,982
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	$-906
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$194,390
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$195,296
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	$131,631
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2011-12-31	$131,231
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2011-12-31	$62,759
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2011-12-31	$63,708
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2011-12-31	$63,708
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2011-12-31	$576
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
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	No
Opinion of an independent qualified public accountant for this plan	2011-12-31	Unqualified
Accountancy firm name	2011-12-31	GERALD J. KASTNER, CPA
Accountancy firm EIN	2011-12-31	952402233
2010 : TAX DEFERRED ANNUITY PLAN OF HSA 2010 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2010-12-31	$16,678
Total unrealized appreciation/depreciation of assets	2010-12-31	$16,678
Total income from all sources (including contributions)	2010-12-31	$27,295
Total of all expenses incurred	2010-12-31	$8,216
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$8,216
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$8,621
Value of total assets at end of year	2010-12-31	$195,296
Value of total assets at beginning of year	2010-12-31	$176,217
Total interest from all sources	2010-12-31	$1,996
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$1,000,000
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$8,621
Participant contributions at end of year	2010-12-31	$357
Participant contributions at beginning of year	2010-12-31	$1,605
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	$19,079
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$195,296
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$176,217
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	$131,231
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2010-12-31	$107,916
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2010-12-31	$63,708
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2010-12-31	$66,696
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2010-12-31	$66,696
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2010-12-31	$1,996
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
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$8,216
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	No
Opinion of an independent qualified public accountant for this plan	2010-12-31	Unqualified
Accountancy firm name	2010-12-31	GERALD J. KASTNER, CPA
Accountancy firm EIN	2010-12-31	952402233

Form 5500 Responses for TAX DEFERRED ANNUITY PLAN OF HSA

2009: TAX DEFERRED ANNUITY PLAN OF HSA 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	First time form 5500 has been submitted	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

MUTUAL OF AMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88668 )

Policy contract number

248045-A

Policy instance

Insurance contract or identification number	248045-A
Number of Individuals Covered	30
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of fees paid to insurance company	USD $6
Are there contracts with allocated funds for group deferred annuity?	Yes
Contracts With Unallocated Funds Deposit Administration	1
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	HUMAN SERVICES ASSOCIATION
Employer identification number (EIN):	951816054
NAIC Classification:	813000
NAIC Description:	Religious, Grantmaking, Civic, Professional, and Similar Organizations

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:
Company Identification Number:	C0729827