401k Plan data: ANGELS AT HOME DEFINED BENEFIT PLAN plan

ANGELS AT HOME DEFINED BENEFIT PLAN 401k Plan overview

Plan Name	ANGELS AT HOME DEFINED BENEFIT PLAN
Plan identification number	002

ANGELS AT HOME DEFINED BENEFIT PLAN Benefits

401k Plan Type	Defined Benefit Pension
Plan Features/Benefits	Benefits are primarily pay related

401k Sponsoring company profile

AMERICA AT HOME HEALTH CARE AND NURSING SERVICES LTD has sponsored the creation of one or more 401k plans.

Company Name: AMERICA AT HOME HEALTH CARE AND NURSING SERVICES LTD

Employer identification number (EIN): 352244336

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ANGELS AT HOME DEFINED BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2012-01-01 GREGORY TAYLOR GREGORY TAYLOR 2016-02-02

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
002	2012-01-01	GREGORY TAYLOR		GREGORY TAYLOR	2016-02-02

Plan Statistics for ANGELS AT HOME DEFINED BENEFIT PLAN

401k plan membership statisitcs for ANGELS AT HOME DEFINED BENEFIT PLAN

Measure Date Value
2012: ANGELS AT HOME DEFINED BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 5
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 0
Total of all active and inactive participants 2012-01-01 0
Total participants 2012-01-01 0

Measure	Date	Value
2012: ANGELS AT HOME DEFINED BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	5
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	0
Total of all active and inactive participants	2012-01-01	0
Total participants	2012-01-01	0

Financial Data on ANGELS AT HOME DEFINED BENEFIT PLAN

Measure	Date	Value
2012 : ANGELS AT HOME DEFINED BENEFIT PLAN 2012 401k financial data
Total income from all sources	2012-12-31	$0
Expenses. Total of all expenses incurred	2012-12-31	$12,411
Benefits paid (including direct rollovers)	2012-12-31	$12,411
Total plan assets at end of year	2012-12-31	$0
Total plan assets at beginning of year	2012-12-31	$12,411
Net income (gross income less expenses)	2012-12-31	$-12,411
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$12,411

Form 5500 Responses for ANGELS AT HOME DEFINED BENEFIT PLAN

2012: ANGELS AT HOME DEFINED BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	Yes
2012-01-01	This submission is the final filing	Yes
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Section 412(e)(3) insurance Contracts	Yes
2012-01-01	Plan benefit arrangement – Section 412(e)(3) insurance Contracts	Yes

Insurance Providers Used on plan

THE LAFAYETTE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65242 )

Policy contract number

C5336

Policy instance

Insurance contract or identification number	C5336
Number of Individuals Covered	0
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
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
Insurance broker organization code?	3
Insurance broker name	RICHARD A ONORATO

Potentially related plans

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Company Name:	AMERICA AT HOME HEALTH CARE AND NURSING SERVICES LTD
Employer identification number (EIN):	352244336
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities