401k Plan data: MAZON STATE BANK 401K PS PLAN plan

MAZON STATE BANK 401K PS PLAN 401k Plan overview

Plan Name	MAZON STATE BANK 401K PS PLAN
Plan identification number	002

MAZON STATE BANK 401K PS PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
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.

401k Sponsoring company profile

MAZON STATE BANK has sponsored the creation of one or more 401k plans.

Company Name: MAZON STATE BANK

Employer identification number (EIN): 362017247

NAIC Classification: 522110
NAIC Description: Commercial Banking

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MAZON STATE BANK 401K PS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2016-01-01 MICHAEL BREISCH 2017-05-17 MICHAEL BREISCH 2017-05-17
002 2015-01-01 MICHAEL BREISCH 2016-07-11
002 2014-01-01 MICHAEL BREISCH
002 2013-01-01 MICHAEL BREISCH
002 2012-01-01 MICHAEL BREISCH
002 2011-01-01 MICHAEL BREISCH
002 2010-01-01 MICHAEL BREISCH
002 2009-01-01 MICHAEL BREISCH

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
002	2016-01-01	MICHAEL BREISCH	2017-05-17	MICHAEL BREISCH	2017-05-17
002	2015-01-01	MICHAEL BREISCH	2016-07-11
002	2014-01-01	MICHAEL BREISCH
002	2013-01-01	MICHAEL BREISCH
002	2012-01-01	MICHAEL BREISCH
002	2011-01-01	MICHAEL BREISCH
002	2010-01-01	MICHAEL BREISCH
002	2009-01-01	MICHAEL BREISCH

Plan Statistics for MAZON STATE BANK 401K PS PLAN

401k plan membership statisitcs for MAZON STATE BANK 401K PS PLAN

Measure Date Value
2014: MAZON STATE BANK 401K PS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 38
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 33
Number of retired or separated participants receiving benefits 2014-01-01 1
Number of other retired or separated participants entitled to future benefits 2014-01-01 2
Total of all active and inactive participants 2014-01-01 36
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 36
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 0
2013: MAZON STATE BANK 401K PS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 30
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 33
Number of retired or separated participants receiving benefits 2013-01-01 1
Number of other retired or separated participants entitled to future benefits 2013-01-01 3
Total of all active and inactive participants 2013-01-01 37
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 37
Number of participants with account balances 2013-01-01 31
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: MAZON STATE BANK 401K PS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 33
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 29
Number of retired or separated participants receiving benefits 2012-01-01 1
Number of other retired or separated participants entitled to future benefits 2012-01-01 3
Total of all active and inactive participants 2012-01-01 33
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 33
Number of participants with account balances 2012-01-01 30
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: MAZON STATE BANK 401K PS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 34
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 28
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 5
Total of all active and inactive participants 2011-01-01 33
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 33
Number of participants with account balances 2011-01-01 33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0
2010: MAZON STATE BANK 401K PS PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 34
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 33
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 33
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
Total participants 2010-01-01 33
Number of participants with account balances 2010-01-01 33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 0
2009: MAZON STATE BANK 401K PS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 33
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 28
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 5
Total of all active and inactive participants 2009-01-01 33
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 33
Number of participants with account balances 2009-01-01 33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2014: MAZON STATE BANK 401K PS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	38
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	33
Number of retired or separated participants receiving benefits	2014-01-01	1
Number of other retired or separated participants entitled to future benefits	2014-01-01	2
Total of all active and inactive participants	2014-01-01	36
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	36
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	0
2013: MAZON STATE BANK 401K PS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	30
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	33
Number of retired or separated participants receiving benefits	2013-01-01	1
Number of other retired or separated participants entitled to future benefits	2013-01-01	3
Total of all active and inactive participants	2013-01-01	37
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	37
Number of participants with account balances	2013-01-01	31
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: MAZON STATE BANK 401K PS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	33
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	29
Number of retired or separated participants receiving benefits	2012-01-01	1
Number of other retired or separated participants entitled to future benefits	2012-01-01	3
Total of all active and inactive participants	2012-01-01	33
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	33
Number of participants with account balances	2012-01-01	30
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: MAZON STATE BANK 401K PS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	34
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	28
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	5
Total of all active and inactive participants	2011-01-01	33
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	33
Number of participants with account balances	2011-01-01	33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2010: MAZON STATE BANK 401K PS PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	34
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	33
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	33
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	33
Number of participants with account balances	2010-01-01	33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	0
2009: MAZON STATE BANK 401K PS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	33
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	28
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	5
Total of all active and inactive participants	2009-01-01	33
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	33
Number of participants with account balances	2009-01-01	33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on MAZON STATE BANK 401K PS PLAN

Measure	Date	Value
2014 : MAZON STATE BANK 401K PS PLAN 2014 401k financial data
Transfers to/from the plan	2014-12-31	$0
Total income from all sources	2014-12-31	$349,996
Expenses. Total of all expenses incurred	2014-12-31	$203,129
Benefits paid (including direct rollovers)	2014-12-31	$202,985
Total plan assets at end of year	2014-12-31	$2,588,875
Total plan assets at beginning of year	2014-12-31	$2,442,008
Value of fidelity bond covering the plan	2014-12-31	$1,000,000
Total contributions received or receivable from participants	2014-12-31	$103,584
Expenses. Other expenses not covered elsewhere	2014-12-31	$144
Contributions received from other sources (not participants or employers)	2014-12-31	$13,264
Other income received	2014-12-31	$169,834
Net income (gross income less expenses)	2014-12-31	$146,867
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$2,588,875
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$2,442,008
Assets. Value of participant loans	2014-12-31	$13,408
Total contributions received or receivable from employer(s)	2014-12-31	$63,314
Value of certain deemed distributions of participant loans	2014-12-31	$0
Value of corrective distributions	2014-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2014-12-31	$0
Minimum employer required contribution for this plan year	2014-12-31	$0
Amount contributed by the employer to the plan for this plan year	2014-12-31	$0
2013 : MAZON STATE BANK 401K PS PLAN 2013 401k financial data
Transfers to/from the plan	2013-12-31	$34
Total income from all sources	2013-12-31	$582,883
Expenses. Total of all expenses incurred	2013-12-31	$80,154
Benefits paid (including direct rollovers)	2013-12-31	$79,989
Total plan assets at end of year	2013-12-31	$2,442,008
Total plan assets at beginning of year	2013-12-31	$1,939,245
Value of fidelity bond covering the plan	2013-12-31	$1,000,000
Total contributions received or receivable from participants	2013-12-31	$95,119
Expenses. Other expenses not covered elsewhere	2013-12-31	$165
Contributions received from other sources (not participants or employers)	2013-12-31	$0
Other income received	2013-12-31	$441,075
Net income (gross income less expenses)	2013-12-31	$502,729
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$2,442,008
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$1,939,245
Assets. Value of participant loans	2013-12-31	$21,414
Total contributions received or receivable from employer(s)	2013-12-31	$46,689
Value of certain deemed distributions of participant loans	2013-12-31	$0
Value of corrective distributions	2013-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2013-12-31	$0
Minimum employer required contribution for this plan year	2013-12-31	$0
Amount contributed by the employer to the plan for this plan year	2013-12-31	$0
2012 : MAZON STATE BANK 401K PS PLAN 2012 401k financial data
Transfers to/from the plan	2012-12-31	$22
Total income from all sources	2012-12-31	$365,331
Expenses. Total of all expenses incurred	2012-12-31	$50,962
Benefits paid (including direct rollovers)	2012-12-31	$50,805
Total plan assets at end of year	2012-12-31	$1,939,245
Total plan assets at beginning of year	2012-12-31	$1,624,854
Value of fidelity bond covering the plan	2012-12-31	$1,000,000
Total contributions received or receivable from participants	2012-12-31	$103,195
Expenses. Other expenses not covered elsewhere	2012-12-31	$157
Contributions received from other sources (not participants or employers)	2012-12-31	$0
Other income received	2012-12-31	$211,806
Net income (gross income less expenses)	2012-12-31	$314,369
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$1,939,245
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$1,624,854
Assets. Value of participant loans	2012-12-31	$23,036
Total contributions received or receivable from employer(s)	2012-12-31	$50,330
Value of certain deemed distributions of participant loans	2012-12-31	$0
Value of corrective distributions	2012-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2012-12-31	$0
Minimum employer required contribution for this plan year	2012-12-31	$0
Amount contributed by the employer to the plan for this plan year	2012-12-31	$0
2011 : MAZON STATE BANK 401K PS PLAN 2011 401k financial data
Transfers to/from the plan	2011-12-31	$0
Total income from all sources	2011-12-31	$41,774
Expenses. Total of all expenses incurred	2011-12-31	$17,272
Benefits paid (including direct rollovers)	2011-12-31	$17,165
Total plan assets at end of year	2011-12-31	$1,624,854
Total plan assets at beginning of year	2011-12-31	$1,600,352
Value of fidelity bond covering the plan	2011-12-31	$1,000,000
Total contributions received or receivable from participants	2011-12-31	$113,402
Expenses. Other expenses not covered elsewhere	2011-12-31	$107
Contributions received from other sources (not participants or employers)	2011-12-31	$0
Other income received	2011-12-31	$-122,986
Net income (gross income less expenses)	2011-12-31	$24,502
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$1,624,854
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$1,600,352
Assets. Value of participant loans	2011-12-31	$26,682
Total contributions received or receivable from employer(s)	2011-12-31	$51,358
Value of certain deemed distributions of participant loans	2011-12-31	$0
Value of corrective distributions	2011-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2011-12-31	$0
Minimum employer required contribution for this plan year	2011-12-31	$0
Amount contributed by the employer to the plan for this plan year	2011-12-31	$0
2010 : MAZON STATE BANK 401K PS PLAN 2010 401k financial data
Transfers to/from the plan	2010-12-31	$4
Total income from all sources	2010-12-31	$328,336
Expenses. Total of all expenses incurred	2010-12-31	$36,413
Benefits paid (including direct rollovers)	2010-12-31	$36,210
Total plan assets at end of year	2010-12-31	$1,600,352
Total plan assets at beginning of year	2010-12-31	$1,308,425
Value of fidelity bond covering the plan	2010-12-31	$1,000,000
Total contributions received or receivable from participants	2010-12-31	$99,733
Expenses. Other expenses not covered elsewhere	2010-12-31	$203
Contributions received from other sources (not participants or employers)	2010-12-31	$0
Other income received	2010-12-31	$179,692
Net income (gross income less expenses)	2010-12-31	$291,923
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$1,600,352
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$1,308,425
Assets. Value of participant loans	2010-12-31	$38,245
Total contributions received or receivable from employer(s)	2010-12-31	$48,911
Value of certain deemed distributions of participant loans	2010-12-31	$0
Value of corrective distributions	2010-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2010-12-31	$0
Minimum employer required contribution for this plan year	2010-12-31	$0
Amount contributed by the employer to the plan for this plan year	2010-12-31	$0
2009 : MAZON STATE BANK 401K PS PLAN 2009 401k financial data
Funding deficiency by the employer to the plan for this plan year	2009-12-31	$0
Minimum employer required contribution for this plan year	2009-12-31	$0
Amount contributed by the employer to the plan for this plan year	2009-12-31	$0

Form 5500 Responses for MAZON STATE BANK 401K PS PLAN

2014: MAZON STATE BANK 401K PS 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	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: MAZON STATE BANK 401K PS 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	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: MAZON STATE BANK 401K PS 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	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: MAZON STATE BANK 401K PS 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	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: MAZON STATE BANK 401K PS 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	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: MAZON STATE BANK 401K PS 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	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-710822

Policy instance

Insurance contract or identification number	GA-710822
Number of Individuals Covered	35
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,101
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?	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 $7,101
Insurance broker organization code?	3
Insurance broker name	MERRILL LYNCH LIFE AGENCY INC

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-710822

Policy instance

Insurance contract or identification number	GA-710822
Number of Individuals Covered	31
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,781
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?	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 $5,781
Insurance broker organization code?	3
Insurance broker name	MERRILL LYNCH LIFE AGENCY

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-710822

Policy instance

Insurance contract or identification number	GA-710822
Number of Individuals Covered	30
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,737
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?	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 $4,737
Insurance broker organization code?	3
Insurance broker name	MERRILL LYNCH LIFE AGENCY

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-710822

Policy instance

Insurance contract or identification number	GA-710822
Number of Individuals Covered	33
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,436
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?	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

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-710822

Policy instance

Insurance contract or identification number	GA-710822
Number of Individuals Covered	33
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,639
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?	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 $3,639
Insurance broker organization code?	3
Insurance broker name	MERRILL LYNCH LIFE AGENCY

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Company Name:	MAZON STATE BANK
Employer identification number (EIN):	362017247
NAIC Classification:	522110
NAIC Description:	Commercial Banking