401k Plan data: BOURBON HEIGHTS, INC. RETIREMENT PLAN plan

BOURBON HEIGHTS, INC. RETIREMENT PLAN 401k Plan overview

Plan Name	BOURBON HEIGHTS, INC. RETIREMENT PLAN
Plan identification number	003

BOURBON HEIGHTS, INC. RETIREMENT PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

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 403(b)(1) arrangement - See Limited Pension Plan Reporting instructions for Code section 403(b)(1) arrangements for certain exempt organizations.

401k Sponsoring company profile

BOURBON HEIGHTS, INC. has sponsored the creation of one or more 401k plans.

Company Name: BOURBON HEIGHTS, INC.

Employer identification number (EIN): 610650767

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BOURBON HEIGHTS, INC. RETIREMENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
003 2012-01-01 CHARLOTTE ROBERTS
003 2011-01-01 ANGELA G. FORSYTHE
003 2010-01-01 ANGELA G. FORSYTHE
003 2009-01-01 ANGELA FORSYTHE

Plan id#	Filing Submission Date	Name of Administrator
003	2012-01-01	CHARLOTTE ROBERTS
003	2011-01-01	ANGELA G. FORSYTHE
003	2010-01-01	ANGELA G. FORSYTHE
003	2009-01-01	ANGELA FORSYTHE

Plan Statistics for BOURBON HEIGHTS, INC. RETIREMENT PLAN

401k plan membership statisitcs for BOURBON HEIGHTS, INC. RETIREMENT PLAN

Measure Date Value
2012: BOURBON HEIGHTS, INC. RETIREMENT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 162
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 163
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 2012-01-01 163
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 163
Number of participants with account balances 2012-01-01 154
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 59
2011: BOURBON HEIGHTS, INC. RETIREMENT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 169
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 153
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 0
Total of all active and inactive participants 2011-01-01 153
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 153
Number of participants with account balances 2011-01-01 153
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 53
2010: BOURBON HEIGHTS, INC. RETIREMENT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 165
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 169
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 2010-01-01 169
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
Total participants 2010-01-01 169
Number of participants with account balances 2010-01-01 90
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 59
2009: BOURBON HEIGHTS, INC. RETIREMENT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 154
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 161
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 0
Total of all active and inactive participants 2009-01-01 161
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 161
Number of participants with account balances 2009-01-01 96
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 37

Measure	Date	Value
2012: BOURBON HEIGHTS, INC. RETIREMENT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	162
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	163
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	163
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	163
Number of participants with account balances	2012-01-01	154
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	59
2011: BOURBON HEIGHTS, INC. RETIREMENT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	169
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	153
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	0
Total of all active and inactive participants	2011-01-01	153
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	153
Number of participants with account balances	2011-01-01	153
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	53
2010: BOURBON HEIGHTS, INC. RETIREMENT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	165
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	169
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	169
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	169
Number of participants with account balances	2010-01-01	90
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	59
2009: BOURBON HEIGHTS, INC. RETIREMENT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	154
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	161
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	0
Total of all active and inactive participants	2009-01-01	161
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	161
Number of participants with account balances	2009-01-01	96
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	37

Financial Data on BOURBON HEIGHTS, INC. RETIREMENT PLAN

Measure	Date	Value
2012 : BOURBON HEIGHTS, INC. RETIREMENT 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	$194,787
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$52,755
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$52,304
Value of total corrective distributions	2012-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$114,547
Value of total assets at end of year	2012-12-31	$1,247,300
Value of total assets at beginning of year	2012-12-31	$1,105,268
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$451
Total interest from all sources	2012-12-31	$17,225
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	$500,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$65,250
Participant contributions at end of year	2012-12-31	$0
Participant contributions at beginning of year	2012-12-31	$83
Assets. Other investments not covered elsewhere at end of year	2012-12-31	$656,312
Assets. Other investments not covered elsewhere at beginning of year	2012-12-31	$532,606
Income. Received or receivable in cash from other sources (including rollovers)	2012-12-31	$0
Other income not declared elsewhere	2012-12-31	$63,015
Total non interest bearing cash at end of year	2012-12-31	$0
Total non interest bearing cash at beginning of year	2012-12-31	$6,280
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	$142,032
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$1,247,300
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$1,105,268
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
Investment advisory and management fees	2012-12-31	$0
Interest earned on other investments	2012-12-31	$17,225
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$590,988
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$565,607
Net investment gain/loss from pooled separate accounts	2012-12-31	$0
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	Yes
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Contributions received in cash from employer	2012-12-31	$49,297
Employer contributions (assets) at end of year	2012-12-31	$0
Employer contributions (assets) at beginning of year	2012-12-31	$692
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$52,304
Contract administrator fees	2012-12-31	$451
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
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2012-12-31	Disclaimer
Accountancy firm name	2012-12-31	JONES, NALE & MATTINGLY PLC
Accountancy firm EIN	2012-12-31	610420207
2011 : BOURBON HEIGHTS, INC. RETIREMENT PLAN 2011 401k financial data
Total unrealized appreciation/depreciation of assets	2011-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total income from all sources (including contributions)	2011-12-31	$126,866
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$166,360
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$165,123
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$113,651
Value of total assets at end of year	2011-12-31	$1,105,268
Value of total assets at beginning of year	2011-12-31	$1,144,762
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$1,237
Total interest from all sources	2011-12-31	$17,960
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Was this plan covered by a fidelity bond	2011-12-31	Yes
Value of fidelity bond cover	2011-12-31	$500,000
If this is an individual account plan, was there a blackout period	2011-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2011-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$66,874
Participant contributions at end of year	2011-12-31	$83
Participant contributions at beginning of year	2011-12-31	$83
Assets. Other investments not covered elsewhere at end of year	2011-12-31	$532,606
Assets. Other investments not covered elsewhere at beginning of year	2011-12-31	$535,785
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2011-12-31	$1,659
Other income not declared elsewhere	2011-12-31	$-4,745
Total non interest bearing cash at end of year	2011-12-31	$6,280
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Value of net income/loss	2011-12-31	$-39,494
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$1,105,268
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$1,144,762
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-12-31	No
Were any leases to which the plan was party in default or uncollectible	2011-12-31	No
Interest earned on other investments	2011-12-31	$17,960
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-12-31	$565,607
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2011-12-31	$583,723
Net investment gain/loss from pooled separate accounts	2011-12-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-12-31	No
Was there a failure to transmit to the plan any participant contributions	2011-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2011-12-31	No
Contributions received in cash from employer	2011-12-31	$46,777
Employer contributions (assets) at end of year	2011-12-31	$692
Employer contributions (assets) at beginning of year	2011-12-31	$23,512
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$165,123
Contract administrator fees	2011-12-31	$1,237
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	2011-12-31	No
Did the plan have assets held for investment	2011-12-31	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	2011-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2011-12-31	Disclaimer
Accountancy firm name	2011-12-31	DEMING, MALONE, LIVESAY & OSTROFF
Accountancy firm EIN	2011-12-31	611064249
2010 : BOURBON HEIGHTS, INC. RETIREMENT PLAN 2010 401k financial data
Total unrealized appreciation/depreciation of assets	2010-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$0
Total income from all sources (including contributions)	2010-12-31	$200,274
Total loss/gain on sale of assets	2010-12-31	$0
Total of all expenses incurred	2010-12-31	$115,682
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$115,133
Value of total corrective distributions	2010-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$116,976
Value of total assets at end of year	2010-12-31	$1,144,762
Value of total assets at beginning of year	2010-12-31	$1,060,170
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$549
Total interest from all sources	2010-12-31	$16,817
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$500,000
If this is an individual account plan, was there a blackout period	2010-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$62,472
Participant contributions at end of year	2010-12-31	$83
Assets. Other investments not covered elsewhere at end of year	2010-12-31	$535,785
Assets. Other investments not covered elsewhere at beginning of year	2010-12-31	$550,710
Value of other receiveables (less allowance for doubtful accounts) at end of year	2010-12-31	$1,659
Other income not declared elsewhere	2010-12-31	$66,481
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Value of net income/loss	2010-12-31	$84,592
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$1,144,762
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$1,060,170
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Interest earned on other investments	2010-12-31	$16,817
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$583,723
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$496,627
Net investment gain/loss from pooled separate accounts	2010-12-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2010-12-31	No
Was there a failure to transmit to the plan any participant contributions	2010-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Contributions received in cash from employer	2010-12-31	$54,504
Employer contributions (assets) at end of year	2010-12-31	$23,512
Employer contributions (assets) at beginning of year	2010-12-31	$12,833
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$115,133
Contract administrator fees	2010-12-31	$549
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	2010-12-31	No
Did the plan have assets held for investment	2010-12-31	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	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2010-12-31	Disclaimer
Accountancy firm name	2010-12-31	DEMING, MALONE, LIVESAY & OSTROFF
Accountancy firm EIN	2010-12-31	611064249
2009 : BOURBON HEIGHTS, INC. RETIREMENT PLAN 2009 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2009-12-31	$0

Form 5500 Responses for BOURBON HEIGHTS, INC. RETIREMENT PLAN

2012: BOURBON HEIGHTS, INC. RETIREMENT 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
2011: BOURBON HEIGHTS, INC. RETIREMENT 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 benefit arrangement – Insurance	Yes
2010: BOURBON HEIGHTS, INC. RETIREMENT 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 benefit arrangement – Insurance	Yes
2009: BOURBON HEIGHTS, INC. RETIREMENT 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 benefit arrangement – Insurance	Yes

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BOURBON HEIGHTS, INC. RETIREMENT PLAN [EIN = 610605767]

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Company Name:	BOURBON HEIGHTS, INC.
Employer identification number (EIN):	610650767
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities