401k Plan data: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN plan

FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 401k Plan overview

Plan Name	FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN
Plan identification number	001

FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

FOND DU LAC LUTHERAN HOME, INC. has sponsored the creation of one or more 401k plans.

Company Name: FOND DU LAC LUTHERAN HOME, INC.

Employer identification number (EIN): 390806344

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2023-01-01 GARY THORPE 2024-06-10
001 2022-01-01 GARY THORPE 2023-06-14
001 2021-01-01 GARY THORPE 2022-05-03
001 2020-01-01 GARY THORPE 2021-07-05
001 2019-01-01
001 2018-01-01
001 2017-01-01 GARY THORPE
001 2017-01-01 GARY THORPE
001 2016-01-01 GARY THORPE
001 2015-01-01 GARY THORPE
001 2014-01-01 GARY THORPE
001 2013-01-01 GARY THORPE
001 2012-01-01 GARY THORPE
001 2011-01-01 GARY THORPE
001 2010-01-01 GARY THORPE
001 2009-01-01 GARY THORPE GARY THORPE 2010-05-06

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2023-01-01	GARY THORPE	2024-06-10
001	2022-01-01	GARY THORPE	2023-06-14
001	2021-01-01	GARY THORPE	2022-05-03
001	2020-01-01	GARY THORPE	2021-07-05
001	2019-01-01
001	2018-01-01
001	2017-01-01	GARY THORPE
001	2017-01-01	GARY THORPE
001	2016-01-01	GARY THORPE
001	2015-01-01	GARY THORPE
001	2014-01-01	GARY THORPE
001	2013-01-01	GARY THORPE
001	2012-01-01	GARY THORPE
001	2011-01-01	GARY THORPE
001	2010-01-01	GARY THORPE
001	2009-01-01	GARY THORPE		GARY THORPE	2010-05-06

Plan Statistics for FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN

401k plan membership statisitcs for FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN

Measure Date Value
2019: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 51
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 34
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 16
Total of all active and inactive participants 2019-01-01 50
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 50
Number of participants with account balances 2019-01-01 29
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 3
2018: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 69
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 41
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 10
Total of all active and inactive participants 2018-01-01 51
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 51
Number of participants with account balances 2018-01-01 28
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 1
2017: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 71
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 58
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 11
Total of all active and inactive participants 2017-01-01 69
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 69
Number of participants with account balances 2017-01-01 31
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 0
2016: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 81
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 57
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 14
Total of all active and inactive participants 2016-01-01 71
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 71
Number of participants with account balances 2016-01-01 32
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0
2015: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 79
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 78
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 3
Total of all active and inactive participants 2015-01-01 81
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 81
Number of participants with account balances 2015-01-01 35
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 0
2014: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 68
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 76
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 3
Total of all active and inactive participants 2014-01-01 79
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 79
Number of participants with account balances 2014-01-01 35
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 1
2013: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 83
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 63
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 5
Total of all active and inactive participants 2013-01-01 68
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 68
Number of participants with account balances 2013-01-01 40
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 133
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 79
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 4
Total of all active and inactive participants 2012-01-01 83
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 83
Number of participants with account balances 2012-01-01 46
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 135
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 130
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 3
Total of all active and inactive participants 2011-01-01 133
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 133
Number of participants with account balances 2011-01-01 52
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0
2010: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 132
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 3
Total of all active and inactive participants 2010-01-01 135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
Total participants 2010-01-01 135
Number of participants with account balances 2010-01-01 54
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 0
2009: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 107
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 115
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 3
Total of all active and inactive participants 2009-01-01 118
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 118
Number of participants with account balances 2009-01-01 54
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: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	51
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	34
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	16
Total of all active and inactive participants	2019-01-01	50
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	50
Number of participants with account balances	2019-01-01	29
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	3
2018: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	69
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	41
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	10
Total of all active and inactive participants	2018-01-01	51
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	51
Number of participants with account balances	2018-01-01	28
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	1
2017: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	71
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	58
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	11
Total of all active and inactive participants	2017-01-01	69
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	69
Number of participants with account balances	2017-01-01	31
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	0
2016: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	81
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	57
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	14
Total of all active and inactive participants	2016-01-01	71
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	71
Number of participants with account balances	2016-01-01	32
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0
2015: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	79
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	78
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	3
Total of all active and inactive participants	2015-01-01	81
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	81
Number of participants with account balances	2015-01-01	35
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	0
2014: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	68
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	76
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	3
Total of all active and inactive participants	2014-01-01	79
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	79
Number of participants with account balances	2014-01-01	35
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	1
2013: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	83
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	63
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	5
Total of all active and inactive participants	2013-01-01	68
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	68
Number of participants with account balances	2013-01-01	40
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	133
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	79
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	4
Total of all active and inactive participants	2012-01-01	83
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	83
Number of participants with account balances	2012-01-01	46
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	135
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	130
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	3
Total of all active and inactive participants	2011-01-01	133
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	133
Number of participants with account balances	2011-01-01	52
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2010: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	132
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	3
Total of all active and inactive participants	2010-01-01	135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	135
Number of participants with account balances	2010-01-01	54
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	0
2009: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	107
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	115
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	3
Total of all active and inactive participants	2009-01-01	118
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	118
Number of participants with account balances	2009-01-01	54
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN

Measure	Date	Value
2019 : FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2019 401k financial data
Total income from all sources	2019-12-31	$203,960
Expenses. Total of all expenses incurred	2019-12-31	$54,172
Benefits paid (including direct rollovers)	2019-12-31	$38,930
Total plan assets at end of year	2019-12-31	$1,015,095
Total plan assets at beginning of year	2019-12-31	$865,307
Value of fidelity bond covering the plan	2019-12-31	$1,000,000
Total contributions received or receivable from participants	2019-12-31	$25,378
Other income received	2019-12-31	$174,509
Net income (gross income less expenses)	2019-12-31	$149,788
Net plan assets at end of year (total assets less liabilities)	2019-12-31	$1,015,095
Net plan assets at beginning of year (total assets less liabilities)	2019-12-31	$865,307
Total contributions received or receivable from employer(s)	2019-12-31	$4,073
Expenses. Administrative service providers (salaries,fees and commissions)	2019-12-31	$15,242
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-12-31	$0
2018 : FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2018 401k financial data
Total income from all sources	2018-12-31	$-27,279
Expenses. Total of all expenses incurred	2018-12-31	$73,118
Benefits paid (including direct rollovers)	2018-12-31	$61,731
Total plan assets at end of year	2018-12-31	$865,307
Total plan assets at beginning of year	2018-12-31	$965,704
Value of fidelity bond covering the plan	2018-12-31	$1,000,000
Total contributions received or receivable from participants	2018-12-31	$25,698
Other income received	2018-12-31	$-57,872
Net income (gross income less expenses)	2018-12-31	$-100,397
Net plan assets at end of year (total assets less liabilities)	2018-12-31	$865,307
Net plan assets at beginning of year (total assets less liabilities)	2018-12-31	$965,704
Total contributions received or receivable from employer(s)	2018-12-31	$4,895
Expenses. Administrative service providers (salaries,fees and commissions)	2018-12-31	$11,387
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-12-31	$0
2017 : FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2017 401k financial data
Total income from all sources	2017-12-31	$169,705
Expenses. Total of all expenses incurred	2017-12-31	$194,200
Benefits paid (including direct rollovers)	2017-12-31	$184,620
Total plan assets at end of year	2017-12-31	$968,207
Total plan assets at beginning of year	2017-12-31	$992,702
Value of fidelity bond covering the plan	2017-12-31	$500,000
Total contributions received or receivable from participants	2017-12-31	$27,143
Contributions received from other sources (not participants or employers)	2017-12-31	$0
Other income received	2017-12-31	$137,319
Net income (gross income less expenses)	2017-12-31	$-24,495
Net plan assets at end of year (total assets less liabilities)	2017-12-31	$968,207
Net plan assets at beginning of year (total assets less liabilities)	2017-12-31	$992,702
Total contributions received or receivable from employer(s)	2017-12-31	$5,243
Expenses. Administrative service providers (salaries,fees and commissions)	2017-12-31	$9,580
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2017-12-31	$0
2016 : FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2016 401k financial data
Total income from all sources	2016-12-31	$112,318
Expenses. Total of all expenses incurred	2016-12-31	$92,210
Benefits paid (including direct rollovers)	2016-12-31	$82,653
Total plan assets at end of year	2016-12-31	$992,702
Total plan assets at beginning of year	2016-12-31	$972,594
Value of fidelity bond covering the plan	2016-12-31	$500,000
Total contributions received or receivable from participants	2016-12-31	$34,951
Other income received	2016-12-31	$71,419
Net income (gross income less expenses)	2016-12-31	$20,108
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$992,702
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$972,594
Total contributions received or receivable from employer(s)	2016-12-31	$5,948
Expenses. Administrative service providers (salaries,fees and commissions)	2016-12-31	$9,557
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-12-31	$0
2015 : FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2015 401k financial data
Total income from all sources	2015-12-31	$35,285
Expenses. Total of all expenses incurred	2015-12-31	$109,487
Benefits paid (including direct rollovers)	2015-12-31	$101,919
Total plan assets at end of year	2015-12-31	$972,594
Total plan assets at beginning of year	2015-12-31	$1,046,796
Value of fidelity bond covering the plan	2015-12-31	$110,000
Total contributions received or receivable from participants	2015-12-31	$39,116
Contributions received from other sources (not participants or employers)	2015-12-31	$7,618
Other income received	2015-12-31	$-17,902
Net income (gross income less expenses)	2015-12-31	$-74,202
Net plan assets at end of year (total assets less liabilities)	2015-12-31	$972,594
Net plan assets at beginning of year (total assets less liabilities)	2015-12-31	$1,046,796
Total contributions received or receivable from employer(s)	2015-12-31	$6,453
Expenses. Administrative service providers (salaries,fees and commissions)	2015-12-31	$7,568
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2015-12-31	$0
2014 : FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2014 401k financial data
Total income from all sources	2014-12-31	$97,836
Expenses. Total of all expenses incurred	2014-12-31	$82,733
Benefits paid (including direct rollovers)	2014-12-31	$76,094
Total plan assets at end of year	2014-12-31	$1,046,796
Total plan assets at beginning of year	2014-12-31	$1,031,693
Value of fidelity bond covering the plan	2014-12-31	$20,000
Total contributions received or receivable from participants	2014-12-31	$42,650
Other income received	2014-12-31	$48,285
Net income (gross income less expenses)	2014-12-31	$15,103
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$1,046,796
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$1,031,693
Total contributions received or receivable from employer(s)	2014-12-31	$6,901
Expenses. Administrative service providers (salaries,fees and commissions)	2014-12-31	$6,639
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
2013 : FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2013 401k financial data
Total income from all sources	2013-12-31	$224,594
Expenses. Total of all expenses incurred	2013-12-31	$347,701
Benefits paid (including direct rollovers)	2013-12-31	$334,516
Total plan assets at end of year	2013-12-31	$1,031,693
Total plan assets at beginning of year	2013-12-31	$1,154,800
Value of fidelity bond covering the plan	2013-12-31	$20,000
Total contributions received or receivable from participants	2013-12-31	$50,419
Other income received	2013-12-31	$166,506
Net income (gross income less expenses)	2013-12-31	$-123,107
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$1,031,693
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$1,154,800
Total contributions received or receivable from employer(s)	2013-12-31	$7,669
Expenses. Administrative service providers (salaries,fees and commissions)	2013-12-31	$13,185
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
2012 : FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2012 401k financial data
Total unrealized appreciation/depreciation of assets	2012-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total income from all sources (including contributions)	2012-12-31	$213,015
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$95,125
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$81,955
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$81,137
Value of total assets at end of year	2012-12-31	$1,154,801
Value of total assets at beginning of year	2012-12-31	$1,036,911
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$13,170
Total interest from all sources	2012-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Administrative expenses professional fees incurred	2012-12-31	$13,170
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$250,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$58,832
Participant contributions at end of year	2012-12-31	$0
Participant contributions at beginning of year	2012-12-31	$2,908
Income. Received or receivable in cash from other sources (including rollovers)	2012-12-31	$9,653
Total non interest bearing cash at end of year	2012-12-31	$0
Total non interest bearing cash at beginning of year	2012-12-31	$937
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	$117,890
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$1,154,801
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$1,036,911
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 pooled separate accounts at end of year	2012-12-31	$1,154,801
Value of interest in pooled separate accounts at beginning of year	2012-12-31	$1,031,901
Net investment gain/loss from pooled separate accounts	2012-12-31	$131,878
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	No
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Contributions received in cash from employer	2012-12-31	$12,652
Employer contributions (assets) at end of year	2012-12-31	$0
Employer contributions (assets) at beginning of year	2012-12-31	$1,165
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$81,955
Did the plan have assets held for investment	2012-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2012-12-31	Disclaimer
Accountancy firm name	2012-12-31	WIPFLI LLP
Accountancy firm EIN	2012-12-31	390758449
2011 : FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2011 401k financial data
Total unrealized appreciation/depreciation of assets	2011-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total income from all sources (including contributions)	2011-12-31	$86,894
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$117,331
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$109,429
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$105,930
Value of total assets at end of year	2011-12-31	$1,036,911
Value of total assets at beginning of year	2011-12-31	$1,067,348
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$7,902
Total interest from all sources	2011-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Administrative expenses professional fees incurred	2011-12-31	$630
Was this plan covered by a fidelity bond	2011-12-31	Yes
Value of fidelity bond cover	2011-12-31	$250,000
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	$75,709
Participant contributions at end of year	2011-12-31	$2,908
Income. Received or receivable in cash from other sources (including rollovers)	2011-12-31	$13
Total non interest bearing cash at end of year	2011-12-31	$937
Total non interest bearing cash at beginning of year	2011-12-31	$967
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	$-30,437
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$1,036,911
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$1,067,348
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 pooled separate accounts at end of year	2011-12-31	$1,031,901
Value of interest in pooled separate accounts at beginning of year	2011-12-31	$1,066,381
Net investment gain/loss from pooled separate accounts	2011-12-31	$-19,036
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	$30,208
Employer contributions (assets) at end of year	2011-12-31	$1,165
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$109,429
Contract administrator fees	2011-12-31	$7,272
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	WIPFLI LLP
Accountancy firm EIN	2011-12-31	390758449
2010 : FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2010 401k financial data
Total income from all sources	2010-12-31	$217,503
Expenses. Total of all expenses incurred	2010-12-31	$26,993
Benefits paid (including direct rollovers)	2010-12-31	$17,600
Total plan assets at end of year	2010-12-31	$1,067,348
Total plan assets at beginning of year	2010-12-31	$876,838
Value of fidelity bond covering the plan	2010-12-31	$20,000
Total contributions received or receivable from participants	2010-12-31	$72,382
Other income received	2010-12-31	$114,684
Net income (gross income less expenses)	2010-12-31	$190,510
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$1,067,348
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$876,838
Total contributions received or receivable from employer(s)	2010-12-31	$30,437
Expenses. Administrative service providers (salaries,fees and commissions)	2010-12-31	$9,393
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
2009 : FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT 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 FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN

2019: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT 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	No
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	Yes
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: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT 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	Yes
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: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	Yes
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	Yes
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: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT 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	Yes
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: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT 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	Yes
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: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT 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	Yes
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: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT 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	Yes
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: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT 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	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: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT 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	Yes
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: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT 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	Yes
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: FOND DU LAC LUTHERAN HOME, INC. 401(K) UNION RETIREMENT 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	Yes
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

55673

Policy instance

Insurance contract or identification number	55673
Number of Individuals Covered	29
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $648
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?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	648
Additional information about fees paid to insurance broker	TPA FEES
Insurance broker organization code?	5

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

55673

Policy instance

Insurance contract or identification number	55673
Number of Individuals Covered	28
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,779
Total amount of fees paid to insurance company	USD $709
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?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,779
Insurance broker organization code?	7
Amount paid for insurance broker fees	709
Additional information about fees paid to insurance broker	TPA COMPENSATION

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

55673

Policy instance

Insurance contract or identification number	55673
Number of Individuals Covered	34
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,596
Total amount of fees paid to insurance company	USD $827
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?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,596
Insurance broker organization code?	7
Amount paid for insurance broker fees	827
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	PPG RETIREMENT PLAN SERVICES

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

55673

Policy instance

Insurance contract or identification number	55673
Number of Individuals Covered	35
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,147
Total amount of fees paid to insurance company	USD $1,015
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,147
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	7
Insurance broker name	PPG RETIREMENT PLAN SERVICES

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

55673

Policy instance

Insurance contract or identification number	55673
Number of Individuals Covered	36
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,258
Total amount of fees paid to insurance company	USD $896
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,258
Insurance broker organization code?	7
Amount paid for insurance broker fees	896
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	PPG RETIREMENT PLAN SERVICES

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

55673

Policy instance

Insurance contract or identification number	55673
Number of Individuals Covered	40
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,590
Total amount of fees paid to insurance company	USD $1,211
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,590
Insurance broker organization code?	7
Amount paid for insurance broker fees	1211
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	PPG RETIREMENT PLAN SERVICES

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

55673

Policy instance

Insurance contract or identification number	55673
Number of Individuals Covered	46
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,537
Total amount of fees paid to insurance company	USD $1,092
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,537
Insurance broker organization code?	7
Amount paid for insurance broker fees	1092
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	PPG RETIREMENT PLAN SERVICES

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

55673

Policy instance

Insurance contract or identification number	55673
Number of Individuals Covered	52
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,505
Total amount of fees paid to insurance company	USD $1,161
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

55673

Policy instance

Insurance contract or identification number	55673
Number of Individuals Covered	54
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $5,559
Total amount of fees paid to insurance company	USD $675
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,559
Insurance broker organization code?	7
Amount paid for insurance broker fees	675
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	PPG RETIREMENT PLAN SERVICES

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Company Name:	FOND DU LAC LUTHERAN HOME, INC.
Employer identification number (EIN):	390806344
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities