401k Plan data: THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN plan

THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 401k Plan overview

Plan Name	THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN
Plan identification number	003

THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

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 403(b)(1) arrangement - See Limited Pension Plan Reporting instructions for Code section 403(b)(1) arrangements for certain exempt organizations.
Code section 403(b)(7) accounts - See Limited Pension Plan Reporting instructions for Code section 403(b)(7) custodial accounts for regulated investment company stock for certain exempt organizations.
Participant-directed brokerage accounts provided as an investment option under the plan.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.

401k Sponsoring company profile

DELNOR-COMMUNITY HOSPITAL has sponsored the creation of one or more 401k plans.

Company Name: DELNOR-COMMUNITY HOSPITAL

Employer identification number (EIN): 363484281

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
003 2012-01-01 SHAWN FITZGERALD
003 2011-01-01 ANN PATRICK
003 2009-01-01 ANN PATRICK

Plan id#	Filing Submission Date	Name of Administrator
003	2012-01-01	SHAWN FITZGERALD
003	2011-01-01	ANN PATRICK
003	2009-01-01	ANN PATRICK

Plan Statistics for THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN

401k plan membership statisitcs for THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN

Measure Date Value
2012: THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,700
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 0
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 0
Number of participants with account balances 2012-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 1,749
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,354
Number of retired or separated participants receiving benefits 2011-01-01 13
Number of other retired or separated participants entitled to future benefits 2011-01-01 327
Total of all active and inactive participants 2011-01-01 1,694
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 6
Total participants 2011-01-01 1,700
Number of participants with account balances 2011-01-01 1,504
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0
2009: THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 1,972
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 1,671
Number of retired or separated participants receiving benefits 2009-01-01 4
Number of other retired or separated participants entitled to future benefits 2009-01-01 522
Total of all active and inactive participants 2009-01-01 2,197
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 8
Total participants 2009-01-01 2,205
Number of participants with account balances 2009-01-01 2,033
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2012: THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,700
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	0
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	0
Number of participants with account balances	2012-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	1,749
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,354
Number of retired or separated participants receiving benefits	2011-01-01	13
Number of other retired or separated participants entitled to future benefits	2011-01-01	327
Total of all active and inactive participants	2011-01-01	1,694
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	6
Total participants	2011-01-01	1,700
Number of participants with account balances	2011-01-01	1,504
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2009: THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	1,972
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	1,671
Number of retired or separated participants receiving benefits	2009-01-01	4
Number of other retired or separated participants entitled to future benefits	2009-01-01	522
Total of all active and inactive participants	2009-01-01	2,197
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	8
Total participants	2009-01-01	2,205
Number of participants with account balances	2009-01-01	2,033
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN

Measure	Date	Value
2012 : THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2012 401k financial data
Total transfer of assets from this plan	2012-05-31	$57,142,530
Total income from all sources (including contributions)	2012-05-31	$3,810,890
Total of all expenses incurred	2012-05-31	$4,097,384
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-05-31	$4,087,549
Expenses. Certain deemed distributions of participant loans	2012-05-31	$7,635
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-05-31	$2,020,991
Value of total assets at end of year	2012-05-31	$0
Value of total assets at beginning of year	2012-05-31	$57,429,024
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-05-31	$2,200
Total interest from all sources	2012-05-31	$194,212
Total dividends received (eg from common stock, registered investment company shares)	2012-05-31	$154,953
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-05-31	Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan	2012-05-31	$0
Total dividends received from registered investment company shares (eg mutual funds)	2012-05-31	$154,953
Was this plan covered by a fidelity bond	2012-05-31	Yes
Value of fidelity bond cover	2012-05-31	$1,000,000
If this is an individual account plan, was there a blackout period	2012-05-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-05-31	$0
Were there any nonexempt tranactions with any party-in-interest	2012-05-31	No
Contributions received from participants	2012-05-31	$1,171,726
Participant contributions at end of year	2012-05-31	$0
Participant contributions at beginning of year	2012-05-31	$843,202
Assets. Other investments not covered elsewhere at end of year	2012-05-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2012-05-31	$680,594
Income. Received or receivable in cash from other sources (including rollovers)	2012-05-31	$14,983
Other income not declared elsewhere	2012-05-31	$8,833
Administrative expenses (other) incurred	2012-05-31	$2,200
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-05-31	No
Value of net income/loss	2012-05-31	$-286,494
Value of net assets at end of year (total assets less liabilities)	2012-05-31	$0
Value of net assets at beginning of year (total assets less liabilities)	2012-05-31	$57,429,024
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-05-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-05-31	No
Were any leases to which the plan was party in default or uncollectible	2012-05-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2012-05-31	$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2012-05-31	$43,202,898
Interest on participant loans	2012-05-31	$17,227
Interest earned on other investments	2012-05-31	$176,985
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-05-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-05-31	$12,702,330
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2012-05-31	$1,431,901
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-05-31	No
Was there a failure to transmit to the plan any participant contributions	2012-05-31	No
Has the plan failed to provide any benefit when due under the plan	2012-05-31	No
Contributions received in cash from employer	2012-05-31	$834,282
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-05-31	$4,087,549
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2012-05-31	No
Did the plan have assets held for investment	2012-05-31	No
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	2012-05-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-05-31	Yes
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-05-31	Yes
Opinion of an independent qualified public accountant for this plan	2012-05-31	Disclaimer
Accountancy firm name	2012-05-31	MUELLER & CO, LLP
Accountancy firm EIN	2012-05-31	362658780
2011 : THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2011 401k financial data
Total income from all sources (including contributions)	2011-12-31	$5,982,734
Total of all expenses incurred	2011-12-31	$6,228,961
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$6,213,871
Expenses. Certain deemed distributions of participant loans	2011-12-31	$7,943
Value of total corrective distributions	2011-12-31	$1,106
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$5,676,787
Value of total assets at end of year	2011-12-31	$57,429,024
Value of total assets at beginning of year	2011-12-31	$57,675,251
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$6,041
Total interest from all sources	2011-12-31	$462,651
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$718,524
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2011-12-31	$718,524
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
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2011-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$3,390,288
Participant contributions at end of year	2011-12-31	$843,202
Participant contributions at beginning of year	2011-12-31	$710,797
Assets. Other investments not covered elsewhere at end of year	2011-12-31	$680,594
Assets. Other investments not covered elsewhere at beginning of year	2011-12-31	$680,888
Income. Received or receivable in cash from other sources (including rollovers)	2011-12-31	$127,756
Other income not declared elsewhere	2011-12-31	$-10,269
Administrative expenses (other) incurred	2011-12-31	$6,041
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	$-246,227
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$57,429,024
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$57,675,251
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	$43,202,898
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2011-12-31	$44,009,164
Interest on participant loans	2011-12-31	$35,042
Interest earned on other investments	2011-12-31	$427,609
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-12-31	$12,702,330
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2011-12-31	$12,274,402
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2011-12-31	$-864,959
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	$2,158,743
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$6,213,871
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	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	Yes
Opinion of an independent qualified public accountant for this plan	2011-12-31	Disclaimer
Accountancy firm name	2011-12-31	MUELLER & CO, LLP
Accountancy firm EIN	2011-12-31	362658780
2010 : THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2010 401k financial data
Total income from all sources (including contributions)	2010-12-31	$11,732,770
Total of all expenses incurred	2010-12-31	$7,314,826
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$7,280,285
Expenses. Certain deemed distributions of participant loans	2010-12-31	$29,590
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$5,966,086
Value of total assets at end of year	2010-12-31	$57,675,251
Value of total assets at beginning of year	2010-12-31	$53,257,307
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$4,951
Total interest from all sources	2010-12-31	$470,016
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$865,638
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	$865,638
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
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$3,490,345
Participant contributions at end of year	2010-12-31	$710,797
Participant contributions at beginning of year	2010-12-31	$598,741
Assets. Other investments not covered elsewhere at end of year	2010-12-31	$680,888
Assets. Other investments not covered elsewhere at beginning of year	2010-12-31	$1,309,394
Income. Received or receivable in cash from other sources (including rollovers)	2010-12-31	$180,703
Other income not declared elsewhere	2010-12-31	$62,143
Administrative expenses (other) incurred	2010-12-31	$4,951
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	$4,417,944
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$57,675,251
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$53,257,307
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	$44,009,164
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2010-12-31	$38,345,122
Interest on participant loans	2010-12-31	$27,785
Interest earned on other investments	2010-12-31	$442,231
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$12,274,402
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$13,004,050
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2010-12-31	$4,368,887
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	$2,295,038
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$7,280,285
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2010-12-31	No
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	MUELLER & CO, LLP
Accountancy firm EIN	2010-12-31	362658780
2009 : THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY 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 THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN

2012: THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	This submission is the final filing	Yes
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
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: THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2009: THE DELNOR-COMMUNITY HOSPITAL TAX DEFERRED ANNUITY 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

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Company Name:	DELNOR-COMMUNITY HOSPITAL
Employer identification number (EIN):	363484281
NAIC Classification:	622000
NAIC Description:	Hospitals