401k Plan data: FAIR OAKS LODGE 401(K) PLAN plan

FAIR OAKS LODGE 401(K) PLAN 401k Plan overview

Plan Name	FAIR OAKS LODGE 401(K) PLAN
Plan identification number	001

FAIR OAKS LODGE 401(K) 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.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

LSS OF WADENA, LLC has sponsored the creation of one or more 401k plans.

Company Name: LSS OF WADENA, LLC

Employer identification number (EIN): 454632615

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FAIR OAKS LODGE 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2018-01-01 AMBER ROGOTZKE
001 2017-01-01
001 2016-01-01
001 2015-01-01 MIKE ANDERSON
001 2014-01-01 LYN SEBENALER
001 2013-01-01 RICH BLANCHARD
001 2012-09-01 RICHARD BLANCHARD

Plan Statistics for FAIR OAKS LODGE 401(K) PLAN

401k plan membership statisitcs for FAIR OAKS LODGE 401(K) PLAN

Measure Date Value
2018: FAIR OAKS LODGE 401(K) PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 186
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 0
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 0
Total of all active and inactive participants 2018-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 0
Number of participants with account balances 2018-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 0
2017: FAIR OAKS LODGE 401(K) PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 182
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 132
Number of retired or separated participants receiving benefits 2017-01-01 1
Number of other retired or separated participants entitled to future benefits 2017-01-01 53
Total of all active and inactive participants 2017-01-01 186
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 186
Number of participants with account balances 2017-01-01 112
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 0
2016: FAIR OAKS LODGE 401(K) PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 111
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 72
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 59
Total of all active and inactive participants 2016-01-01 131
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 131
Number of participants with account balances 2016-01-01 94
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0
2015: FAIR OAKS LODGE 401(K) PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 145
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 62
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 48
Total of all active and inactive participants 2015-01-01 110
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 110
Number of participants with account balances 2015-01-01 98
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 0
2014: FAIR OAKS LODGE 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 132
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 103
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 42
Total of all active and inactive participants 2014-01-01 145
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 145
Number of participants with account balances 2014-01-01 125
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: FAIR OAKS LODGE 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 113
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 105
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 25
Total of all active and inactive participants 2013-01-01 130
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 130
Number of participants with account balances 2013-01-01 106
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: FAIR OAKS LODGE 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year 2012-09-01 120
Total number of active participants reported on line 7a of the Form 5500 2012-09-01 105
Number of retired or separated participants receiving benefits 2012-09-01 0
Number of other retired or separated participants entitled to future benefits 2012-09-01 7
Total of all active and inactive participants 2012-09-01 112
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-09-01 0
Total participants 2012-09-01 112
Number of participants with account balances 2012-09-01 93
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-09-01 0

Measure	Date	Value
2018: FAIR OAKS LODGE 401(K) PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	186
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	0
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	0
Total of all active and inactive participants	2018-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	0
Number of participants with account balances	2018-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	0
2017: FAIR OAKS LODGE 401(K) PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	182
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	132
Number of retired or separated participants receiving benefits	2017-01-01	1
Number of other retired or separated participants entitled to future benefits	2017-01-01	53
Total of all active and inactive participants	2017-01-01	186
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	186
Number of participants with account balances	2017-01-01	112
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	0
2016: FAIR OAKS LODGE 401(K) PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	111
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	72
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	59
Total of all active and inactive participants	2016-01-01	131
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	131
Number of participants with account balances	2016-01-01	94
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0
2015: FAIR OAKS LODGE 401(K) PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	145
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	62
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	48
Total of all active and inactive participants	2015-01-01	110
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	110
Number of participants with account balances	2015-01-01	98
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	0
2014: FAIR OAKS LODGE 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	132
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	103
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	42
Total of all active and inactive participants	2014-01-01	145
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	145
Number of participants with account balances	2014-01-01	125
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: FAIR OAKS LODGE 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	113
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	105
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	25
Total of all active and inactive participants	2013-01-01	130
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	130
Number of participants with account balances	2013-01-01	106
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: FAIR OAKS LODGE 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year	2012-09-01	120
Total number of active participants reported on line 7a of the Form 5500	2012-09-01	105
Number of retired or separated participants receiving benefits	2012-09-01	0
Number of other retired or separated participants entitled to future benefits	2012-09-01	7
Total of all active and inactive participants	2012-09-01	112
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-09-01	0
Total participants	2012-09-01	112
Number of participants with account balances	2012-09-01	93
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-09-01	0

Financial Data on FAIR OAKS LODGE 401(K) PLAN

Measure	Date	Value
2018 : FAIR OAKS LODGE 401(K) PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-07-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-07-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-07-31	$0
Total income from all sources (including contributions)	2018-07-31	$15,675
Total loss/gain on sale of assets	2018-07-31	$0
Total of all expenses incurred	2018-07-31	$324,905
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-07-31	$316,398
Expenses. Certain deemed distributions of participant loans	2018-07-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-07-31	$11,216
Value of total assets at end of year	2018-07-31	$0
Value of total assets at beginning of year	2018-07-31	$309,230
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-07-31	$8,507
Total interest from all sources	2018-07-31	$84
Total dividends received (eg from common stock, registered investment company shares)	2018-07-31	$4,375
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-07-31	Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan	2018-07-31	$0
Total dividends received from registered investment company shares (eg mutual funds)	2018-07-31	$4,375
Was this plan covered by a fidelity bond	2018-07-31	Yes
Value of fidelity bond cover	2018-07-31	$100,000
If this is an individual account plan, was there a blackout period	2018-07-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-07-31	$0
Were there any nonexempt tranactions with any party-in-interest	2018-07-31	No
Contributions received from participants	2018-07-31	$11,216
Participant contributions at end of year	2018-07-31	$0
Participant contributions at beginning of year	2018-07-31	$1,983
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-07-31	No
Value of net income/loss	2018-07-31	$-309,230
Value of net assets at end of year (total assets less liabilities)	2018-07-31	$0
Value of net assets at beginning of year (total assets less liabilities)	2018-07-31	$309,230
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-07-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-07-31	No
Were any leases to which the plan was party in default or uncollectible	2018-07-31	No
Value of interest in pooled separate accounts at end of year	2018-07-31	$0
Value of interest in pooled separate accounts at beginning of year	2018-07-31	$298,476
Interest on participant loans	2018-07-31	$42
Income. Interest from loans (other than to participants)	2018-07-31	$42
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2018-07-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2018-07-31	$8,771
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-07-31	No
Was there a failure to transmit to the plan any participant contributions	2018-07-31	No
Has the plan failed to provide any benefit when due under the plan	2018-07-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-07-31	$316,398
Contract administrator fees	2018-07-31	$8,507
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	2018-07-31	No
Did the plan have assets held for investment	2018-07-31	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	2018-07-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-07-31	Yes
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-07-31	Yes
Opinion of an independent qualified public accountant for this plan	2018-07-31	Disclaimer
Accountancy firm name	2018-07-31	BETTS & HAYES, LTD.
Accountancy firm EIN	2018-07-31	411619880
2017 : FAIR OAKS LODGE 401(K) 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	$74,460
Total loss/gain on sale of assets	2017-12-31	$0
Total of all expenses incurred	2017-12-31	$46,123
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$44,926
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$36,288
Value of total assets at end of year	2017-12-31	$309,230
Value of total assets at beginning of year	2017-12-31	$280,893
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$1,197
Total interest from all sources	2017-12-31	$200
Total dividends received (eg from common stock, registered investment company shares)	2017-12-31	$0
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	$0
Administrative expenses professional fees incurred	2017-12-31	$1,197
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$100,000
If this is an individual account plan, was there a blackout period	2017-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2017-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Contributions received from participants	2017-12-31	$36,288
Participant contributions at end of year	2017-12-31	$1,983
Participant contributions at beginning of year	2017-12-31	$4,604
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2017-12-31	$1,891
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	$28,337
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$309,230
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$280,893
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
Value of interest in pooled separate accounts at end of year	2017-12-31	$298,476
Value of interest in pooled separate accounts at beginning of year	2017-12-31	$268,424
Interest on participant loans	2017-12-31	$111
Interest earned on other investments	2017-12-31	$89
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2017-12-31	$8,771
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2017-12-31	$7,865
Net investment gain/loss from pooled separate accounts	2017-12-31	$37,972
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	No
Has the plan failed to provide any benefit when due under the plan	2017-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$43,035
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	BETTS & HAYES, LTD.
Accountancy firm EIN	2017-12-31	411619880
2016 : FAIR OAKS LODGE 401(K) 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	$62,264
Total loss/gain on sale of assets	2016-12-31	$0
Total of all expenses incurred	2016-12-31	$21,537
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$20,714
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$43,804
Value of total assets at end of year	2016-12-31	$280,893
Value of total assets at beginning of year	2016-12-31	$240,166
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$823
Total interest from all sources	2016-12-31	$135
Total dividends received (eg from common stock, registered investment company shares)	2016-12-31	$0
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	$0
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
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2016-12-31	No
Contributions received from participants	2016-12-31	$43,804
Participant contributions at end of year	2016-12-31	$4,604
Participant contributions at beginning of year	2016-12-31	$2,509
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
Value of net income/loss	2016-12-31	$40,727
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$280,893
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$240,166
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 pooled separate accounts at end of year	2016-12-31	$268,424
Value of interest in pooled separate accounts at beginning of year	2016-12-31	$237,657
Interest on participant loans	2016-12-31	$116
Interest earned on other investments	2016-12-31	$19
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2016-12-31	$7,865
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2016-12-31	$0
Net investment gain/loss from pooled separate accounts	2016-12-31	$18,325
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
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$20,714
Contract administrator fees	2016-12-31	$823
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	BETTS & HAYES, LTD.
Accountancy firm EIN	2016-12-31	411619880
2015 : FAIR OAKS LODGE 401(K) PLAN 2015 401k financial data
Total unrealized appreciation/depreciation of assets	2015-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total income from all sources (including contributions)	2015-12-31	$66,623
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$66,684
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$63,359
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$75,214
Value of total assets at end of year	2015-12-31	$240,166
Value of total assets at beginning of year	2015-12-31	$240,227
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$3,325
Total interest from all sources	2015-12-31	$87
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$100,000
If this is an individual account plan, was there a blackout period	2015-12-31	Yes
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2015-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$75,214
Participant contributions at end of year	2015-12-31	$2,509
Participant contributions at beginning of year	2015-12-31	$1,531
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Value of net income/loss	2015-12-31	$-61
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$240,166
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$240,227
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-12-31	No
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Value of interest in pooled separate accounts at end of year	2015-12-31	$237,657
Value of interest in pooled separate accounts at beginning of year	2015-12-31	$237,450
Interest on participant loans	2015-12-31	$87
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2015-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2015-12-31	$1,246
Net investment gain/loss from pooled separate accounts	2015-12-31	$-8,678
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-12-31	No
Was there a failure to transmit to the plan any participant contributions	2015-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$63,359
Contract administrator fees	2015-12-31	$3,325
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	2015-12-31	Yes
Did the plan have assets held for investment	2015-12-31	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	2015-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2015-12-31	Disclaimer
Accountancy firm name	2015-12-31	BETTS & HAYES, LTD.
Accountancy firm EIN	2015-12-31	411619880
2014 : FAIR OAKS LODGE 401(K) PLAN 2014 401k financial data
Total unrealized appreciation/depreciation of assets	2014-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total income from all sources (including contributions)	2014-12-31	$91,610
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$68,710
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$65,684
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$81,771
Value of total assets at end of year	2014-12-31	$240,227
Value of total assets at beginning of year	2014-12-31	$217,327
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$3,026
Total interest from all sources	2014-12-31	$46
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$100,000
If this is an individual account plan, was there a blackout period	2014-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$80,533
Participant contributions at end of year	2014-12-31	$1,531
Participant contributions at beginning of year	2014-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2014-12-31	$1,238
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Value of net income/loss	2014-12-31	$22,900
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$240,227
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$217,327
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-12-31	No
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Value of interest in pooled separate accounts at end of year	2014-12-31	$237,450
Value of interest in pooled separate accounts at beginning of year	2014-12-31	$216,878
Interest on participant loans	2014-12-31	$38
Interest earned on other investments	2014-12-31	$8
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-12-31	$1,246
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-12-31	$449
Net investment gain/loss from pooled separate accounts	2014-12-31	$9,793
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-12-31	No
Was there a failure to transmit to the plan any participant contributions	2014-12-31	No
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$65,684
Contract administrator fees	2014-12-31	$3,026
Did the plan have assets held for investment	2014-12-31	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	2014-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2014-12-31	Disclaimer
Accountancy firm name	2014-12-31	BETTS & HAYES, LTD.
Accountancy firm EIN	2014-12-31	411619880
2013 : FAIR OAKS LODGE 401(K) PLAN 2013 401k financial data
Total unrealized appreciation/depreciation of assets	2013-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$0
Total income from all sources (including contributions)	2013-12-31	$151,768
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$4,420
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$3,042
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$129,433
Value of total assets at end of year	2013-12-31	$217,327
Value of total assets at beginning of year	2013-12-31	$69,979
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$1,378
Total interest from all sources	2013-12-31	$1
Total dividends received (eg from common stock, registered investment company shares)	2013-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2013-12-31	No
Was this plan covered by a fidelity bond	2013-12-31	Yes
Value of fidelity bond cover	2013-12-31	$100,000
If this is an individual account plan, was there a blackout period	2013-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$73,978
Income. Received or receivable in cash from other sources (including rollovers)	2013-12-31	$55,455
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Value of net income/loss	2013-12-31	$147,348
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$217,327
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$69,979
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-12-31	No
Were any leases to which the plan was party in default or uncollectible	2013-12-31	No
Value of interest in pooled separate accounts at end of year	2013-12-31	$216,878
Value of interest in pooled separate accounts at beginning of year	2013-12-31	$69,934
Interest earned on other investments	2013-12-31	$1
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2013-12-31	$449
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2013-12-31	$45
Net investment gain/loss from pooled separate accounts	2013-12-31	$22,334
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	No
Was there a failure to transmit to the plan any participant contributions	2013-12-31	No
Has the plan failed to provide any benefit when due under the plan	2013-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$3,042
Contract administrator fees	2013-12-31	$1,378
Did the plan have assets held for investment	2013-12-31	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	2013-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2013-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2013-12-31	Disclaimer
Accountancy firm name	2013-12-31	BETTS & HAYES, LTD.
Accountancy firm EIN	2013-12-31	411619880
2012 : FAIR OAKS LODGE 401(K) PLAN 2012 401k financial data
Total unrealized appreciation/depreciation of assets	2012-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total income from all sources (including contributions)	2012-12-31	$70,034
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$55
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$68,627
Value of total assets at end of year	2012-12-31	$69,979
Value of total assets at beginning of year	2012-12-31	$0
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$55
Total interest from all sources	2012-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$100,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$26,514
Income. Received or receivable in cash from other sources (including rollovers)	2012-12-31	$42,113
Administrative expenses (other) incurred	2012-12-31	$55
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net income/loss	2012-12-31	$69,979
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$69,979
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Value of interest in pooled separate accounts at end of year	2012-12-31	$69,934
Value of interest in pooled separate accounts at beginning of year	2012-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$45
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$0
Net investment gain/loss from pooled separate accounts	2012-12-31	$1,407
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	No
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Did the plan have assets held for investment	2012-12-31	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	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No

Form 5500 Responses for FAIR OAKS LODGE 401(K) PLAN

2018: FAIR OAKS LODGE 401(K) 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	Yes
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
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: FAIR OAKS LODGE 401(K) 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: FAIR OAKS LODGE 401(K) 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 – Insurance	Yes
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: FAIR OAKS LODGE 401(K) 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 – Insurance	Yes
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: FAIR OAKS LODGE 401(K) 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
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: FAIR OAKS LODGE 401(K) 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
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: FAIR OAKS LODGE 401(K) PLAN 2012 form 5500 responses
2012-09-01	Type of plan entity	Single employer plan
2012-09-01	First time form 5500 has been submitted	Yes
2012-09-01	Submission has been amended	No
2012-09-01	This submission is the final filing	No
2012-09-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2012-09-01	Plan is a collectively bargained plan	No
2012-09-01	Plan funding arrangement – Insurance	Yes
2012-09-01	Plan funding arrangement – Trust	Yes
2012-09-01	Plan benefit arrangement – Insurance	Yes
2012-09-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

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

Policy contract number

916873-01

Policy instance

Insurance contract or identification number	916873-01
Number of Individuals Covered	0
Insurance policy start date	2018-01-01
Insurance policy end date	2018-07-31
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?	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

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

Policy contract number

916873-01

Policy instance

Insurance contract or identification number	916873-01
Number of Individuals Covered	111
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
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?	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

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

Policy contract number

916873-01

Policy instance

Insurance contract or identification number	916873-01
Number of Individuals Covered	100
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
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?	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

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

803464-0000

Policy instance

Insurance contract or identification number	803464-0000
Number of Individuals Covered	0
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $60
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 $0
Amount paid for insurance broker fees	60
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	5
Insurance broker name	GOLDLEAF PARTNERS

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

803494-000

Policy instance

Insurance contract or identification number	803494-000
Number of Individuals Covered	125
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $250
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
Amount paid for insurance broker fees	250
Additional information about fees paid to insurance broker	TPA ALLOWANCE
Insurance broker organization code?	5
Insurance broker name	GOLDLEAF PARTNERS

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

803494-000

Policy instance

Insurance contract or identification number	803494-000
Number of Individuals Covered	105
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $145
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
Amount paid for insurance broker fees	145
Additional information about fees paid to insurance broker	TPA ALLOWANCE
Insurance broker organization code?	5
Insurance broker name	GOLDLEAF PARTNERS

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

803494-000

Policy instance

Insurance contract or identification number	803494-000
Number of Individuals Covered	93
Insurance policy start date	2012-09-01
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 $1
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
Amount paid for insurance broker fees	1
Additional information about fees paid to insurance broker	TPA ALLOWANCE
Insurance broker organization code?	5
Insurance broker name	UNIVERSAL RETIREMENT SOLUTIONS, INC

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Company Name:	LSS OF WADENA, LLC
Employer identification number (EIN):	454632615
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Plan id#	Filing Submission Date	Name of Administrator
001	2018-01-01	AMBER ROGOTZKE
001	2017-01-01
001	2016-01-01
001	2015-01-01	MIKE ANDERSON
001	2014-01-01	LYN SEBENALER
001	2013-01-01	RICH BLANCHARD
001	2012-09-01	RICHARD BLANCHARD