401k Plan data: ADCARE FLEXIBLE SPENDING plan

ADCARE FLEXIBLE SPENDING 401k Plan overview

Plan Name	ADCARE FLEXIBLE SPENDING
Plan identification number	520

ADCARE FLEXIBLE SPENDING Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Other welfare benefit cover

401k Sponsoring company profile

ADCARE HOSPITAL OF WORCESTER, INC. has sponsored the creation of one or more 401k plans.

Company Name: ADCARE HOSPITAL OF WORCESTER, INC.

Employer identification number (EIN): 042053042

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ADCARE FLEXIBLE SPENDING

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
520 2011-01-01 DAVID W. HILLIS
520 2010-01-01 DAVID W. HILLIS
520 2009-01-01 DAVID HILLIS JOAN BERTRAND 2010-07-13

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
520	2011-01-01	DAVID W. HILLIS
520	2010-01-01	DAVID W. HILLIS
520	2009-01-01	DAVID HILLIS	JOAN BERTRAND	2010-07-13

Plan Statistics for ADCARE FLEXIBLE SPENDING

401k plan membership statisitcs for ADCARE FLEXIBLE SPENDING

Measure Date Value
2011: ADCARE FLEXIBLE SPENDING 2011 401k membership
Total participants, beginning-of-year 2011-01-01 25
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 0
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 0
Total of all active and inactive participants 2011-01-01 0
2010: ADCARE FLEXIBLE SPENDING 2010 401k membership
Total participants, beginning-of-year 2010-01-01 20
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 25
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 0
Total of all active and inactive participants 2010-01-01 25
Total participants 2010-01-01 25
2009: ADCARE FLEXIBLE SPENDING 2009 401k membership
Total participants, beginning-of-year 2009-01-01 25
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 20
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 20
Total participants 2009-01-01 20
Number of employers contributing to the scheme 2009-01-01 2

Measure	Date	Value
2011: ADCARE FLEXIBLE SPENDING 2011 401k membership
Total participants, beginning-of-year	2011-01-01	25
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	0
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	0
Total of all active and inactive participants	2011-01-01	0
2010: ADCARE FLEXIBLE SPENDING 2010 401k membership
Total participants, beginning-of-year	2010-01-01	20
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	25
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	0
Total of all active and inactive participants	2010-01-01	25
Total participants	2010-01-01	25
2009: ADCARE FLEXIBLE SPENDING 2009 401k membership
Total participants, beginning-of-year	2009-01-01	25
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	20
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	20
Total participants	2009-01-01	20
Number of employers contributing to the scheme	2009-01-01	2

Financial Data on ADCARE FLEXIBLE SPENDING

Measure	Date	Value
2011 : ADCARE FLEXIBLE SPENDING 2011 401k financial data
Total plan assets at end of year	2011-12-31	$0
Total plan assets at beginning of year	2011-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$0

Form 5500 Responses for ADCARE FLEXIBLE SPENDING

2011: ADCARE FLEXIBLE SPENDING 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	This submission is the final filing	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: ADCARE FLEXIBLE SPENDING 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: ADCARE FLEXIBLE SPENDING 2009 form 5500 responses
2009-01-01	Type of plan entity	Multi-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 – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

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Company Name:	ADCARE HOSPITAL OF WORCESTER, INC.
Employer identification number (EIN):	042053042
NAIC Classification:	622000
NAIC Description:	Hospitals