401k Plan data: CHATHAM FURNITURE REPRODUCTIONS, INC. plan

CHATHAM FURNITURE REPRODUCTIONS, INC. 401k Plan overview

Plan Name	CHATHAM FURNITURE REPRODUCTIONS, INC.
Plan identification number	501

CHATHAM FURNITURE REPRODUCTIONS, INC. Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision)

401k Sponsoring company profile

CHATHAM FURNITURE REPRODUCTIONS, INC. has sponsored the creation of one or more 401k plans.

Company Name: CHATHAM FURNITURE REPRODUCTIONS, INC.

Employer identification number (EIN): 020464006

NAIC Classification: 321900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CHATHAM FURNITURE REPRODUCTIONS, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2012-01-01 PAUL KAPELA 2013-01-28 PAUL KAPELA 2013-01-28
501 2011-01-01 PAUL KAPELA

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2012-01-01	PAUL KAPELA	2013-01-28	PAUL KAPELA	2013-01-28
501	2011-01-01	PAUL KAPELA

Plan Statistics for CHATHAM FURNITURE REPRODUCTIONS, INC.

401k plan membership statisitcs for CHATHAM FURNITURE REPRODUCTIONS, INC.

Measure Date Value
2011: CHATHAM FURNITURE REPRODUCTIONS, INC. 2011 401k membership
Total participants, beginning-of-year 2011-01-01 7
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 3
Total of all active and inactive participants 2011-01-01 3
Total participants 2011-01-01 3
Number of participants with account balances 2011-01-01 3
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 4

Measure	Date	Value
2011: CHATHAM FURNITURE REPRODUCTIONS, INC. 2011 401k membership
Total participants, beginning-of-year	2011-01-01	7
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	3
Total of all active and inactive participants	2011-01-01	3
Total participants	2011-01-01	3
Number of participants with account balances	2011-01-01	3
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	4

Financial Data on CHATHAM FURNITURE REPRODUCTIONS, INC.

Measure	Date	Value
2011 : CHATHAM FURNITURE REPRODUCTIONS, INC. 2011 401k financial data
Total income from all sources	2011-12-31	$20,990
Expenses. Total of all expenses incurred	2011-12-31	$20,990
Benefits paid (including direct rollovers)	2011-12-31	$20,990
Total contributions received or receivable from participants	2011-12-31	$10,790
Net income (gross income less expenses)	2011-12-31	$0
Total contributions received or receivable from employer(s)	2011-12-31	$10,200
2010 : CHATHAM FURNITURE REPRODUCTIONS, INC. 2010 401k financial data
Total plan liabilities at end of year	2010-12-31	$0
Total plan liabilities at beginning of year	2010-12-31	$0
Total income from all sources	2010-12-31	$29,764
Expenses. Total of all expenses incurred	2010-12-31	$29,764
Benefits paid (including direct rollovers)	2010-12-31	$29,764
Total plan assets at end of year	2010-12-31	$0
Total plan assets at beginning of year	2010-12-31	$0
Total contributions received or receivable from participants	2010-12-31	$12,465
Net income (gross income less expenses)	2010-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$0
Total contributions received or receivable from employer(s)	2010-12-31	$17,299

Form 5500 Responses for CHATHAM FURNITURE REPRODUCTIONS, INC.

2011: CHATHAM FURNITURE REPRODUCTIONS, INC. 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

0557620000

Policy instance

Insurance contract or identification number	0557620000
Number of Individuals Covered	3
Insurance policy start date	2011-12-01
Insurance policy end date	2012-11-30
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

0557620000

Policy instance

Insurance contract or identification number	0557620000
Number of Individuals Covered	7
Insurance policy start date	2010-12-01
Insurance policy end date	2011-11-30
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	CHATHAM FURNITURE REPRODUCTIONS, INC.
Employer identification number (EIN):	020464006
NAIC Classification:	321900