401k Plan data: MIZNER COUNTRY CLUB RETIREMENT PLAN plan

MIZNER COUNTRY CLUB RETIREMENT PLAN 401k Plan overview

Plan Name	MIZNER COUNTRY CLUB RETIREMENT PLAN
Plan identification number	001

MIZNER COUNTRY CLUB 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.
Plan provides for automatic enrollment in plan that has employee contributions deducted from payroll.
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.

401k Sponsoring company profile

MIZNER COUNTRY CLUB has sponsored the creation of one or more 401k plans.

Company Name: MIZNER COUNTRY CLUB

Employer identification number (EIN): 232970622

NAIC Classification: 713900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MIZNER COUNTRY CLUB RETIREMENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01
001 2021-01-01
001 2020-01-01
001 2019-01-01
001 2018-01-01
001 2017-01-01 JENNIFER CHAVEZ
001 2016-01-01 JENNIFER CHAVEZ
001 2015-01-01 JENNIFER CHAVEZ 2016-10-13
001 2014-01-01 THERESA HANSON 2015-02-10
001 2013-01-01 THERESA HANSON 2014-02-11

Plan Statistics for MIZNER COUNTRY CLUB RETIREMENT PLAN

401k plan membership statisitcs for MIZNER COUNTRY CLUB RETIREMENT PLAN

Measure Date Value
2022: MIZNER COUNTRY CLUB RETIREMENT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 186
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 125
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 51
Total of all active and inactive participants 2022-01-01 176
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 176
Number of participants with account balances 2022-01-01 135
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 1
2021: MIZNER COUNTRY CLUB RETIREMENT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 196
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 123
Number of retired or separated participants receiving benefits 2021-01-01 1
Number of other retired or separated participants entitled to future benefits 2021-01-01 39
Total of all active and inactive participants 2021-01-01 163
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 163
Number of participants with account balances 2021-01-01 120
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0
2020: MIZNER COUNTRY CLUB RETIREMENT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 147
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 126
Number of retired or separated participants receiving benefits 2020-01-01 2
Number of other retired or separated participants entitled to future benefits 2020-01-01 58
Total of all active and inactive participants 2020-01-01 186
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 186
Number of participants with account balances 2020-01-01 150
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: MIZNER COUNTRY CLUB RETIREMENT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 171
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 118
Number of retired or separated participants receiving benefits 2019-01-01 14
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 132
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 132
Number of participants with account balances 2019-01-01 98
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 0
2018: MIZNER COUNTRY CLUB RETIREMENT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 139
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 118
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 37
Total of all active and inactive participants 2018-01-01 155
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 155
Number of participants with account balances 2018-01-01 115
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 1
2017: MIZNER COUNTRY CLUB RETIREMENT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 138
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 115
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 6
Total of all active and inactive participants 2017-01-01 121
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 121
Number of participants with account balances 2017-01-01 84
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 14
2016: MIZNER COUNTRY CLUB RETIREMENT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 106
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 16
Total of all active and inactive participants 2016-01-01 122
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 122
Number of participants with account balances 2016-01-01 90
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 2

Measure	Date	Value
2022: MIZNER COUNTRY CLUB RETIREMENT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	186
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	125
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	51
Total of all active and inactive participants	2022-01-01	176
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	176
Number of participants with account balances	2022-01-01	135
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	1
2021: MIZNER COUNTRY CLUB RETIREMENT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	196
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	123
Number of retired or separated participants receiving benefits	2021-01-01	1
Number of other retired or separated participants entitled to future benefits	2021-01-01	39
Total of all active and inactive participants	2021-01-01	163
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	163
Number of participants with account balances	2021-01-01	120
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
2020: MIZNER COUNTRY CLUB RETIREMENT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	147
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	126
Number of retired or separated participants receiving benefits	2020-01-01	2
Number of other retired or separated participants entitled to future benefits	2020-01-01	58
Total of all active and inactive participants	2020-01-01	186
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	186
Number of participants with account balances	2020-01-01	150
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: MIZNER COUNTRY CLUB RETIREMENT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	171
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	118
Number of retired or separated participants receiving benefits	2019-01-01	14
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	132
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	132
Number of participants with account balances	2019-01-01	98
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	0
2018: MIZNER COUNTRY CLUB RETIREMENT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	139
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	118
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	37
Total of all active and inactive participants	2018-01-01	155
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	155
Number of participants with account balances	2018-01-01	115
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	1
2017: MIZNER COUNTRY CLUB RETIREMENT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	138
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	115
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	6
Total of all active and inactive participants	2017-01-01	121
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	121
Number of participants with account balances	2017-01-01	84
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	14
2016: MIZNER COUNTRY CLUB RETIREMENT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	106
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	16
Total of all active and inactive participants	2016-01-01	122
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	122
Number of participants with account balances	2016-01-01	90
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	2

Financial Data on MIZNER COUNTRY CLUB RETIREMENT PLAN

Measure	Date	Value
2022 : MIZNER COUNTRY CLUB RETIREMENT PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total income from all sources (including contributions)	2022-12-31	$-23,672
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$438,333
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$417,942
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$362,030
Value of total assets at end of year	2022-12-31	$1,870,325
Value of total assets at beginning of year	2022-12-31	$2,332,330
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$20,391
Total interest from all sources	2022-12-31	$3,670
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$500,000
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$303,536
Participant contributions at end of year	2022-12-31	$59,245
Participant contributions at beginning of year	2022-12-31	$103,451
Total non interest bearing cash at end of year	2022-12-31	$0
Total non interest bearing cash at beginning of year	2022-12-31	$1,839
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-462,005
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$1,870,325
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$2,332,330
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Investment advisory and management fees	2022-12-31	$20,391
Value of interest in pooled separate accounts at end of year	2022-12-31	$1,809,486
Value of interest in pooled separate accounts at beginning of year	2022-12-31	$2,227,040
Interest on participant loans	2022-12-31	$3,670
Net investment gain/loss from pooled separate accounts	2022-12-31	$-389,372
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$58,494
Employer contributions (assets) at end of year	2022-12-31	$1,594
Employer contributions (assets) at beginning of year	2022-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$417,942
Did the plan have assets held for investment	2022-12-31	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	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	HOLYFIELD & THOMAS LLC
Accountancy firm EIN	2022-12-31	651083521
2021 : MIZNER COUNTRY CLUB RETIREMENT PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$629,386
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$160,015
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$136,639
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$360,187
Value of total assets at end of year	2021-12-31	$2,332,330
Value of total assets at beginning of year	2021-12-31	$1,862,959
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$23,376
Total interest from all sources	2021-12-31	$3,840
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$21
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Administrative expenses professional fees incurred	2021-12-31	$23,376
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$500,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$296,649
Participant contributions at end of year	2021-12-31	$103,451
Participant contributions at beginning of year	2021-12-31	$49,622
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$7,747
Total non interest bearing cash at end of year	2021-12-31	$1,839
Total non interest bearing cash at beginning of year	2021-12-31	$155
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$469,371
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$2,332,330
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$1,862,959
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$0
Value of interest in pooled separate accounts at end of year	2021-12-31	$2,227,040
Value of interest in pooled separate accounts at beginning of year	2021-12-31	$1,798,956
Interest on participant loans	2021-12-31	$3,840
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-12-31	$14,226
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$265,338
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$55,791
Income. Dividends from preferred stock	2021-12-31	$21
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$136,639
Did the plan have assets held for investment	2021-12-31	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	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	HOLYFIELD & THOMAS LLC
Accountancy firm EIN	2021-12-31	651083521
2020 : MIZNER COUNTRY CLUB RETIREMENT PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$638,568
Total loss/gain on sale of assets	2020-12-31	$222,034
Total of all expenses incurred	2020-12-31	$75,829
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$58,999
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$413,602
Value of total assets at end of year	2020-12-31	$1,862,959
Value of total assets at beginning of year	2020-12-31	$1,300,220
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$16,830
Total interest from all sources	2020-12-31	$2,786
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$146
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Administrative expenses professional fees incurred	2020-12-31	$16,830
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$500,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$291,942
Participant contributions at end of year	2020-12-31	$49,622
Participant contributions at beginning of year	2020-12-31	$48,257
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$65,848
Total non interest bearing cash at end of year	2020-12-31	$155
Total non interest bearing cash at beginning of year	2020-12-31	$176
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$562,739
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$1,862,959
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$1,300,220
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$0
Value of interest in pooled separate accounts at end of year	2020-12-31	$1,798,956
Value of interest in pooled separate accounts at beginning of year	2020-12-31	$1,237,707
Interest on participant loans	2020-12-31	$2,786
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-12-31	$14,226
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-12-31	$14,080
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	No
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$55,812
Income. Dividends from preferred stock	2020-12-31	$146
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$58,999
Did the plan have assets held for investment	2020-12-31	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	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Aggregate proceeds on sale of assets	2020-12-31	$222,034
Opinion of an independent qualified public accountant for this plan	2020-12-31	Disclaimer
Accountancy firm name	2020-12-31	HOLYFIELD & THOMAS LLC
Accountancy firm EIN	2020-12-31	651083521
2019 : MIZNER COUNTRY CLUB RETIREMENT PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total income from all sources (including contributions)	2019-12-31	$545,899
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$134,605
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$118,032
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$371,194
Value of total assets at end of year	2019-12-31	$1,300,220
Value of total assets at beginning of year	2019-12-31	$888,926
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$16,573
Total income from rents	2019-12-31	$0
Total interest from all sources	2019-12-31	$2,188
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$56,512
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2019-12-31	$56,512
Administrative expenses professional fees incurred	2019-12-31	$16,573
Was this plan covered by a fidelity bond	2019-12-31	Yes
Value of fidelity bond cover	2019-12-31	$500,000
If this is an individual account plan, was there a blackout period	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Contributions received from participants	2019-12-31	$234,071
Participant contributions at end of year	2019-12-31	$48,257
Participant contributions at beginning of year	2019-12-31	$22,588
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$90,976
Total non interest bearing cash at end of year	2019-12-31	$176
Total non interest bearing cash at beginning of year	2019-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Value of net income/loss	2019-12-31	$411,294
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$1,300,220
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$888,926
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$853,100
Value of interest in pooled separate accounts at end of year	2019-12-31	$1,237,707
Value of interest in pooled separate accounts at beginning of year	2019-12-31	$0
Interest on participant loans	2019-12-31	$2,188
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-12-31	$14,080
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$13,238
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$88,881
Net investment gain/loss from pooled separate accounts	2019-12-31	$27,124
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Contributions received in cash from employer	2019-12-31	$46,147
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$118,032
Did the plan have assets held for investment	2019-12-31	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	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Accountancy firm name	2019-12-31	HOLYFIELD & THOMAS LLC
Accountancy firm EIN	2019-12-31	651083521
2018 : MIZNER COUNTRY CLUB RETIREMENT PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total income from all sources (including contributions)	2018-12-31	$205,973
Total loss/gain on sale of assets	2018-12-31	$0
Total of all expenses incurred	2018-12-31	$153,740
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$142,833
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$254,243
Value of total assets at end of year	2018-12-31	$888,926
Value of total assets at beginning of year	2018-12-31	$836,693
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$10,907
Total interest from all sources	2018-12-31	$796
Total dividends received (eg from common stock, registered investment company shares)	2018-12-31	$65,095
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2018-12-31	$65,095
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2018-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Contributions received from participants	2018-12-31	$213,844
Participant contributions at end of year	2018-12-31	$22,588
Participant contributions at beginning of year	2018-12-31	$19,081
Participant contributions at end of year	2018-12-31	$0
Participant contributions at beginning of year	2018-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Value of net income/loss	2018-12-31	$52,233
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$888,926
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$836,693
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-12-31	No
Were any leases to which the plan was party in default or uncollectible	2018-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2018-12-31	$853,100
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2018-12-31	$817,597
Interest on participant loans	2018-12-31	$796
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2018-12-31	$13,238
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2018-12-31	$15
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-12-31	$-114,161
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-12-31	No
Was there a failure to transmit to the plan any participant contributions	2018-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2018-12-31	No
Assets. Invements in employer securities at end of year	2018-12-31	$0
Assets. Invements in employer securities at beginning of year	2018-12-31	$0
Contributions received in cash from employer	2018-12-31	$40,399
Employer contributions (assets) at end of year	2018-12-31	$0
Employer contributions (assets) at beginning of year	2018-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$142,833
Contract administrator fees	2018-12-31	$10,907
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	2018-12-31	No
Did the plan have assets held for investment	2018-12-31	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	2018-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2018-12-31	Disclaimer
Accountancy firm name	2018-12-31	HOLYFIELD & THOMAS LLC
Accountancy firm EIN	2018-12-31	651083521
2017 : MIZNER COUNTRY CLUB RETIREMENT PLAN 2017 401k financial data
Total unrealized appreciation/depreciation of assets	2017-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total income from all sources (including contributions)	2017-12-31	$354,908
Total loss/gain on sale of assets	2017-12-31	$0
Total of all expenses incurred	2017-12-31	$70,219
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$60,692
Expenses. Certain deemed distributions of participant loans	2017-12-31	$1,941
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$266,342
Value of total assets at end of year	2017-12-31	$836,693
Value of total assets at beginning of year	2017-12-31	$552,004
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$7,586
Total interest from all sources	2017-12-31	$905
Total dividends received (eg from common stock, registered investment company shares)	2017-12-31	$36,235
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2017-12-31	$36,235
Administrative expenses professional fees incurred	2017-12-31	$0
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2017-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Contributions received from participants	2017-12-31	$211,882
Participant contributions at end of year	2017-12-31	$19,081
Participant contributions at beginning of year	2017-12-31	$25,256
Participant contributions at end of year	2017-12-31	$0
Participant contributions at beginning of year	2017-12-31	$7,620
Income. Received or receivable in cash from other sources (including rollovers)	2017-12-31	$12,052
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2017-12-31	$0
Administrative expenses (other) incurred	2017-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Value of net income/loss	2017-12-31	$284,689
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$836,693
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$552,004
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-12-31	No
Were any leases to which the plan was party in default or uncollectible	2017-12-31	No
Investment advisory and management fees	2017-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2017-12-31	$817,597
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2017-12-31	$517,544
Interest on participant loans	2017-12-31	$905
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2017-12-31	$15
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2017-12-31	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2017-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2017-12-31	$51,426
Net investment gain/loss from pooled separate accounts	2017-12-31	$0
Net investment gain or loss from common/collective trusts	2017-12-31	$0
Net gain/loss from 103.12 investment entities	2017-12-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-12-31	No
Was there a failure to transmit to the plan any participant contributions	2017-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2017-12-31	No
Assets. Invements in employer securities at end of year	2017-12-31	$0
Assets. Invements in employer securities at beginning of year	2017-12-31	$0
Contributions received in cash from employer	2017-12-31	$42,408
Employer contributions (assets) at end of year	2017-12-31	$0
Employer contributions (assets) at beginning of year	2017-12-31	$1,584
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$60,692
Contract administrator fees	2017-12-31	$7,586
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	2017-12-31	No
Did the plan have assets held for investment	2017-12-31	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	2017-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2017-12-31	Disclaimer
Accountancy firm name	2017-12-31	HOLYFIELD & THOMAS LLC
Accountancy firm EIN	2017-12-31	651083521
2016 : MIZNER COUNTRY CLUB RETIREMENT PLAN 2016 401k financial data
Total unrealized appreciation/depreciation of assets	2016-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$0
Total income from all sources (including contributions)	2016-12-31	$196,564
Total loss/gain on sale of assets	2016-12-31	$0
Total of all expenses incurred	2016-12-31	$34,725
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$29,422
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$159,608
Value of total assets at end of year	2016-12-31	$552,004
Value of total assets at beginning of year	2016-12-31	$390,165
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$5,303
Total interest from all sources	2016-12-31	$798
Total dividends received (eg from common stock, registered investment company shares)	2016-12-31	$27,539
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2016-12-31	$27,539
Administrative expenses professional fees incurred	2016-12-31	$5,303
Was this plan covered by a fidelity bond	2016-12-31	Yes
Value of fidelity bond cover	2016-12-31	$100,000
If this is an individual account plan, was there a blackout period	2016-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2016-12-31	No
Contributions received from participants	2016-12-31	$154,796
Participant contributions at end of year	2016-12-31	$25,256
Participant contributions at beginning of year	2016-12-31	$20,664
Participant contributions at end of year	2016-12-31	$7,620
Participant contributions at beginning of year	2016-12-31	$5,348
Income. Received or receivable in cash from other sources (including rollovers)	2016-12-31	$0
Total non interest bearing cash at end of year	2016-12-31	$0
Total non interest bearing cash at beginning of year	2016-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Income. Non cash contributions	2016-12-31	$0
Value of net income/loss	2016-12-31	$161,839
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$552,004
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$390,165
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-12-31	No
Were any leases to which the plan was party in default or uncollectible	2016-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2016-12-31	$517,544
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2016-12-31	$364,153
Interest on participant loans	2016-12-31	$798
Income. Interest from loans (other than to participants)	2016-12-31	$0
Income. Interest from US Government securities	2016-12-31	$0
Income. Interest from corporate debt instruments	2016-12-31	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2016-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2016-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2016-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2016-12-31	$8,619
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-12-31	No
Was there a failure to transmit to the plan any participant contributions	2016-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2016-12-31	No
Contributions received in cash from employer	2016-12-31	$4,812
Employer contributions (assets) at end of year	2016-12-31	$1,584
Employer contributions (assets) at beginning of year	2016-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$29,422
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	2016-12-31	No
Did the plan have assets held for investment	2016-12-31	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	2016-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2016-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2016-12-31	Disclaimer
Accountancy firm name	2016-12-31	HOLYFIELD & THOMAS LLC
Accountancy firm EIN	2016-12-31	651083521

Form 5500 Responses for MIZNER COUNTRY CLUB RETIREMENT PLAN

2022: MIZNER COUNTRY CLUB RETIREMENT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: MIZNER COUNTRY CLUB RETIREMENT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: MIZNER COUNTRY CLUB RETIREMENT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: MIZNER COUNTRY CLUB 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	No
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: MIZNER COUNTRY CLUB 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	No
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: MIZNER COUNTRY CLUB RETIREMENT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
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	No
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: MIZNER COUNTRY CLUB 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	No
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	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

141974

Policy instance

Insurance contract or identification number	141974
Number of Individuals Covered	172
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,014
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	1014
Additional information about fees paid to insurance broker	TPA FEES & COMPENSATION
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

141974

Policy instance

Insurance contract or identification number	141974
Number of Individuals Covered	147
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,947
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 $0
Amount paid for insurance broker fees	2947
Additional information about fees paid to insurance broker	TPA FEES & COMPENSATION
Insurance broker organization code?	5

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68322 )

Policy contract number

335337-01

Policy instance

Insurance contract or identification number	335337-01
Number of Individuals Covered	0
Insurance policy start date	2021-01-01
Insurance policy end date	2021-03-02
Total amount of commissions paid to insurance broker	USD $18
Total amount of fees paid to insurance company	USD $0
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?	Yes
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 $18
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSION
Insurance broker organization code?	3

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68322 )

Policy contract number

335337-01

Policy instance

Insurance contract or identification number	335337-01
Number of Individuals Covered	2
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $217
Total amount of fees paid to insurance company	USD $0
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?	Yes
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 $217
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSION
Insurance broker organization code?	3

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

Policy contract number

141974

Policy instance

Insurance contract or identification number	141974
Number of Individuals Covered	170
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $7,456
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 $0
Amount paid for insurance broker fees	7456
Additional information about fees paid to insurance broker	TPA FEES & COMPENSATION
Insurance broker organization code?	5

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68322 )

Policy contract number

335337-01

Policy instance

Insurance contract or identification number	335337-01
Number of Individuals Covered	2
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,245
Total amount of fees paid to insurance company	USD $0
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?	Yes
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 $5,245
Insurance broker organization code?	3

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

Policy contract number

141974

Policy instance

Insurance contract or identification number	141974
Number of Individuals Covered	656
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
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

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68322 )

Policy contract number

335337-01

Policy instance

Insurance contract or identification number	335337-01
Number of Individuals Covered	2
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $65
Total amount of fees paid to insurance company	USD $0
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?	Yes
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 $65
Insurance broker organization code?	3

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68322 )

Policy contract number

335337-01

Policy instance

Insurance contract or identification number	335337-01
Number of Individuals Covered	2
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $49
Total amount of fees paid to insurance company	USD $0
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?	Yes
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 $49
Insurance broker organization code?	3
Insurance broker name	BRETT SHOFNER

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Company Name:	MIZNER COUNTRY CLUB
Employer identification number (EIN):	232970622
NAIC Classification:	713900