401k Plan data: LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN plan

LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN 401k Plan overview

Plan Name	LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN
Plan identification number	501

LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Other welfare benefit cover Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

LUTHERAN SOCIAL SERVICES OF ND has sponsored the creation of one or more 401k plans.

Company Name: LUTHERAN SOCIAL SERVICES OF ND

Employer identification number (EIN): 450226421

NAIC Classification: 624100
NAIC Description: Individual and Family Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2015-01-01 JESSICA THOMASSON
501 2014-01-01 JESSICA THOMASSON JESSICA THOMASSON 2015-07-28
501 2013-01-01 ROBERT SANDERSON ROBERT SANDERSON 2014-07-28
501 2012-01-01 ROBERT SANDERSON ROBERT SANDERSON 2013-10-11

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2015-01-01	JESSICA THOMASSON
501	2014-01-01	JESSICA THOMASSON	JESSICA THOMASSON	2015-07-28
501	2013-01-01	ROBERT SANDERSON	ROBERT SANDERSON	2014-07-28
501	2012-01-01	ROBERT SANDERSON	ROBERT SANDERSON	2013-10-11

Plan Statistics for LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN

401k plan membership statisitcs for LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN

Measure Date Value
2015: LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 64
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 64
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 64
2014: LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 46
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 64
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 64
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 64
2013: LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 49
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 46
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 46
Total participants 2013-01-01 46
2012: LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 47
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 47
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 47
Total participants 2012-01-01 47

Measure	Date	Value
2015: LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	64
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	64
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	64
2014: LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	46
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	64
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	64
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	64
2013: LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	49
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	46
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	46
Total participants	2013-01-01	46
2012: LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	47
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	47
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	47
Total participants	2012-01-01	47

Form 5500 Responses for LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN

2015: LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA 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 benefit arrangement – Insurance	Yes
2013: LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA 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 benefit arrangement – Insurance	Yes
2012: LUTHERAN SOCIAL SERVICES OF NORTH DAKOTA CAFETERIA 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 benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

DISCOVERY BENEFITS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

LSS

Policy instance

Insurance contract or identification number	LSS
Number of Individuals Covered	64
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
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
Other welfare benefits provided	MEDICAL AND DEPENDENT CARE/LIMITED FLEXIBLE SPENDING ACCOUNT
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

DISCOVERY BENEFITS (National Association of Insurance Commissioners NAIC id number: 54121 )

Policy contract number

450226421-501

Policy instance

Insurance contract or identification number	450226421-501
Number of Individuals Covered	47
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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Company Name:	LUTHERAN SOCIAL SERVICES OF ND
Employer identification number (EIN):	450226421
NAIC Classification:	624100
NAIC Description:	Individual and Family Services