401k Plan data: KINGSLEY HOUSE INC plan

KINGSLEY HOUSE INC 401k Plan overview

Plan Name	KINGSLEY HOUSE INC
Plan identification number	003

KINGSLEY HOUSE INC Benefits

401k Plan Type	Defined Contribution Pension
Plan Features/Benefits	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.

401k Sponsoring company profile

CLOVER NOLA, INC. has sponsored the creation of one or more 401k plans.

Company Name: CLOVER NOLA, INC.

Employer identification number (EIN): 720408940

NAIC Classification: 624100
NAIC Description: Individual and Family Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KINGSLEY HOUSE INC

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
003 2022-01-01 KEITH LIEDERMAN 2023-10-16
003 2021-01-01 KEITH LIEDERMAN 2022-10-17
003 2020-01-01 KEITH LIEDERMAN 2022-01-21
003 2019-01-01
003 2018-01-01
003 2017-01-01 KEITH LIEDERMAN KEITH LIEDERMAN 2018-10-15
003 2017-01-01 KEITH LIEDERMAN KEITH LIEDERMAN 2019-02-06
003 2017-01-01
003 2017-01-01
003 2016-01-01 KEITH LIEDERMAN KEITH LIEDERMAN 2018-04-26
003 2015-01-01 KEITH LIEDERMAN 2016-07-29
003 2014-01-01 KEITH LIEDERMAN 2016-07-29
003 2013-01-01 KEITH LIEDERMAN 2014-07-29
003 2012-01-01 KEITH LIEDERMAN 2013-07-30 KEITH LIEDERMAN 2013-07-30
003 2011-01-01 KEITH LIEDERMAN 2012-07-30
003 2010-01-01 KEITH LIEDERMAN 2011-10-17

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
003	2022-01-01	KEITH LIEDERMAN	2023-10-16
003	2021-01-01	KEITH LIEDERMAN	2022-10-17
003	2020-01-01	KEITH LIEDERMAN	2022-01-21
003	2019-01-01
003	2018-01-01
003	2017-01-01	KEITH LIEDERMAN		KEITH LIEDERMAN	2018-10-15
003	2017-01-01	KEITH LIEDERMAN		KEITH LIEDERMAN	2019-02-06
003	2017-01-01
003	2017-01-01
003	2016-01-01	KEITH LIEDERMAN		KEITH LIEDERMAN	2018-04-26
003	2015-01-01	KEITH LIEDERMAN	2016-07-29
003	2014-01-01	KEITH LIEDERMAN	2016-07-29
003	2013-01-01	KEITH LIEDERMAN	2014-07-29
003	2012-01-01	KEITH LIEDERMAN	2013-07-30	KEITH LIEDERMAN	2013-07-30
003	2011-01-01	KEITH LIEDERMAN	2012-07-30
003	2010-01-01	KEITH LIEDERMAN	2011-10-17

Plan Statistics for KINGSLEY HOUSE INC

401k plan membership statisitcs for KINGSLEY HOUSE INC

Measure Date Value
2022: KINGSLEY HOUSE INC 2022 401k membership
Total participants, beginning-of-year 2022-01-01 294
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 156
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 127
Total of all active and inactive participants 2022-01-01 283
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 1
Total participants 2022-01-01 284
Number of participants with account balances 2022-01-01 283
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 0
2021: KINGSLEY HOUSE INC 2021 401k membership
Total participants, beginning-of-year 2021-01-01 287
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 160
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 133
Total of all active and inactive participants 2021-01-01 293
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 1
Total participants 2021-01-01 294
Number of participants with account balances 2021-01-01 294
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0
2020: KINGSLEY HOUSE INC 2020 401k membership
Total participants, beginning-of-year 2020-01-01 283
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 148
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 138
Total of all active and inactive participants 2020-01-01 286
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 1
Total participants 2020-01-01 287
Number of participants with account balances 2020-01-01 287
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: KINGSLEY HOUSE INC 2019 401k membership
Total participants, beginning-of-year 2019-01-01 271
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 140
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 142
Total of all active and inactive participants 2019-01-01 282
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 1
Total participants 2019-01-01 283
Number of participants with account balances 2019-01-01 282
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 0
2018: KINGSLEY HOUSE INC 2018 401k membership
Total participants, beginning-of-year 2018-01-01 257
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 138
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 132
Total of all active and inactive participants 2018-01-01 270
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 1
Total participants 2018-01-01 271
Number of participants with account balances 2018-01-01 271
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 0
2017: KINGSLEY HOUSE INC 2017 401k membership
Total participants, beginning-of-year 2017-01-01 212
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 131
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 125
Total of all active and inactive participants 2017-01-01 256
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 1
Total participants 2017-01-01 257
Number of participants with account balances 2017-01-01 253
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 0
2016: KINGSLEY HOUSE INC 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 94
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 117
Total of all active and inactive participants 2016-01-01 211
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 1
Total participants 2016-01-01 212
Number of participants with account balances 2016-01-01 208
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0

Measure	Date	Value
2022: KINGSLEY HOUSE INC 2022 401k membership
Total participants, beginning-of-year	2022-01-01	294
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	156
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	127
Total of all active and inactive participants	2022-01-01	283
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	1
Total participants	2022-01-01	284
Number of participants with account balances	2022-01-01	283
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	0
2021: KINGSLEY HOUSE INC 2021 401k membership
Total participants, beginning-of-year	2021-01-01	287
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	160
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	133
Total of all active and inactive participants	2021-01-01	293
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	1
Total participants	2021-01-01	294
Number of participants with account balances	2021-01-01	294
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
2020: KINGSLEY HOUSE INC 2020 401k membership
Total participants, beginning-of-year	2020-01-01	283
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	148
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	138
Total of all active and inactive participants	2020-01-01	286
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	1
Total participants	2020-01-01	287
Number of participants with account balances	2020-01-01	287
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: KINGSLEY HOUSE INC 2019 401k membership
Total participants, beginning-of-year	2019-01-01	271
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	140
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	142
Total of all active and inactive participants	2019-01-01	282
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	1
Total participants	2019-01-01	283
Number of participants with account balances	2019-01-01	282
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	0
2018: KINGSLEY HOUSE INC 2018 401k membership
Total participants, beginning-of-year	2018-01-01	257
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	138
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	132
Total of all active and inactive participants	2018-01-01	270
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	1
Total participants	2018-01-01	271
Number of participants with account balances	2018-01-01	271
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	0
2017: KINGSLEY HOUSE INC 2017 401k membership
Total participants, beginning-of-year	2017-01-01	212
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	131
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	125
Total of all active and inactive participants	2017-01-01	256
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	1
Total participants	2017-01-01	257
Number of participants with account balances	2017-01-01	253
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	0
2016: KINGSLEY HOUSE INC 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	94
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	117
Total of all active and inactive participants	2016-01-01	211
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	1
Total participants	2016-01-01	212
Number of participants with account balances	2016-01-01	208
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0

Financial Data on KINGSLEY HOUSE INC

Measure	Date	Value
2022 : KINGSLEY HOUSE INC 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total income from all sources (including contributions)	2022-12-31	$-156,279
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$414,235
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$414,235
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$270,280
Value of total assets at end of year	2022-12-31	$2,938,284
Value of total assets at beginning of year	2022-12-31	$3,508,798
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$0
Total interest from all sources	2022-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$7,236
Total dividends received from registered investment company shares (eg mutual funds)	2022-12-31	$7,236
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$350,880
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$69,244
Participant contributions at end of year	2022-12-31	$0
Participant contributions at beginning of year	2022-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2022-12-31	$6,951
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-570,514
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$2,938,284
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$3,508,798
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$1,878,000
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$2,460,702
Value of interest in pooled separate accounts at end of year	2022-12-31	$159,509
Value of interest in pooled separate accounts at beginning of year	2022-12-31	$175,917
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-12-31	$900,775
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-12-31	$872,179
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-448,452
Net investment gain/loss from pooled separate accounts	2022-12-31	$14,657
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$194,085
Employer contributions (assets) at end of year	2022-12-31	$0
Employer contributions (assets) at beginning of year	2022-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$414,235
Did the plan have assets held for investment	2022-12-31	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	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Qualified
Accountancy firm name	2022-12-31	WEGMANN DAZET
Accountancy firm EIN	2022-12-31	720870824
2021 : KINGSLEY HOUSE INC 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$669,723
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$181,635
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$181,635
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$275,200
Value of total assets at end of year	2021-12-31	$3,508,798
Value of total assets at beginning of year	2021-12-31	$3,020,710
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$0
Total interest from all sources	2021-12-31	$2,357
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$0
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$301,068
If this is an individual account plan, was there a blackout period	2021-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$58,034
Participant contributions at end of year	2021-12-31	$0
Participant contributions at beginning of year	2021-12-31	$1,839
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$8,642
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$488,088
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$3,508,798
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$3,020,710
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$2,460,702
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$2,023,739
Value of interest in pooled separate accounts at end of year	2021-12-31	$175,917
Value of interest in pooled separate accounts at beginning of year	2021-12-31	$149,441
Interest on participant loans	2021-12-31	$2,357
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-12-31	$872,179
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-12-31	$837,491
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$392,166
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$208,524
Employer contributions (assets) at end of year	2021-12-31	$0
Employer contributions (assets) at beginning of year	2021-12-31	$8,200
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$181,635
Did the plan have assets held for investment	2021-12-31	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	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	WEGMANN DAZET
Accountancy firm EIN	2021-12-31	720870824
2020 : KINGSLEY HOUSE INC 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$582,416
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$366,617
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$366,617
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$233,227
Value of total assets at end of year	2020-12-31	$3,010,671
Value of total assets at beginning of year	2020-12-31	$2,794,872
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$0
Total interest from all sources	2020-12-31	$30,730
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$0
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$278,487
If this is an individual account plan, was there a blackout period	2020-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$29,125
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$215,799
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$3,010,671
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$2,794,872
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-12-31	$2,023,739
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$1,736,818
Value of interest in pooled separate accounts at end of year	2020-12-31	$149,441
Value of interest in pooled separate accounts at beginning of year	2020-12-31	$158,635
Interest earned on other investments	2020-12-31	$30,730
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-12-31	$837,491
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-12-31	$899,419
Expenses. Payments to insurance carriers foe the provision of benefits	2020-12-31	$97,560
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$319,806
Net investment gain/loss from pooled separate accounts	2020-12-31	$-1,347
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$204,102
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$269,057
Did the plan have assets held for investment	2020-12-31	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	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Unqualified
Accountancy firm name	2020-12-31	WEGMANN DAZET
Accountancy firm EIN	2020-12-31	720870824
2019 : KINGSLEY HOUSE INC 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total income from all sources (including contributions)	2019-12-31	$821,423
Total income from all sources (including contributions)	2019-12-31	$821,423
Total loss/gain on sale of assets	2019-12-31	$0
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$389,631
Total of all expenses incurred	2019-12-31	$389,631
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$389,631
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$389,631
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$459,857
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$459,857
Value of total assets at end of year	2019-12-31	$2,794,872
Value of total assets at beginning of year	2019-12-31	$2,363,080
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$0
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$0
Total interest from all sources	2019-12-31	$32,616
Total interest from all sources	2019-12-31	$32,616
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$0
Was this plan covered by a fidelity bond	2019-12-31	Yes
Was this plan covered by a fidelity bond	2019-12-31	Yes
Value of fidelity bond cover	2019-12-31	$236,308
Value of fidelity bond cover	2019-12-31	$236,308
If this is an individual account plan, was there a blackout period	2019-12-31	No
If this is an individual account plan, was there a blackout period	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Contributions received from participants	2019-12-31	$25,306
Contributions received from participants	2019-12-31	$25,306
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$240,137
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$240,137
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Value of net income/loss	2019-12-31	$431,792
Value of net income/loss	2019-12-31	$431,792
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$2,794,872
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$2,363,080
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$1,736,818
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$1,320,509
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$1,320,509
Value of interest in pooled separate accounts at end of year	2019-12-31	$158,635
Value of interest in pooled separate accounts at beginning of year	2019-12-31	$150,732
Value of interest in pooled separate accounts at beginning of year	2019-12-31	$150,732
Interest earned on other investments	2019-12-31	$32,616
Interest earned on other investments	2019-12-31	$32,616
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-12-31	$899,419
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$891,839
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$891,839
Expenses. Payments to insurance carriers foe the provision of benefits	2019-12-31	$210,670
Expenses. Payments to insurance carriers foe the provision of benefits	2019-12-31	$210,670
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$320,570
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$320,570
Net investment gain/loss from pooled separate accounts	2019-12-31	$8,380
Net investment gain/loss from pooled separate accounts	2019-12-31	$8,380
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2019-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Contributions received in cash from employer	2019-12-31	$194,414
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$178,961
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$178,961
Did the plan have assets held for investment	2019-12-31	Yes
Did the plan have assets held for investment	2019-12-31	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	2019-12-31	No
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	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Accountancy firm name	2019-12-31	WEGMANN DAZET
Accountancy firm name	2019-12-31	WEGMANN DAZET
Accountancy firm EIN	2019-12-31	720870824
Accountancy firm EIN	2019-12-31	720870824
2018 : KINGSLEY HOUSE INC 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total income from all sources (including contributions)	2018-12-31	$161,216
Total loss/gain on sale of assets	2018-12-31	$0
Total of all expenses incurred	2018-12-31	$128,252
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$128,252
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$205,454
Value of total assets at end of year	2018-12-31	$2,363,080
Value of total assets at beginning of year	2018-12-31	$2,330,116
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$0
Total interest from all sources	2018-12-31	$32,013
Total dividends received (eg from common stock, registered investment company shares)	2018-12-31	$0
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$200,000
If this is an individual account plan, was there a blackout period	2018-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Contributions received from participants	2018-12-31	$23,226
Income. Received or receivable in cash from other sources (including rollovers)	2018-12-31	$-557
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Value of net income/loss	2018-12-31	$32,964
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$2,363,080
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$2,330,116
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-12-31	No
Were any leases to which the plan was party in default or uncollectible	2018-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2018-12-31	$1,320,509
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2018-12-31	$1,313,509
Value of interest in pooled separate accounts at end of year	2018-12-31	$150,732
Value of interest in pooled separate accounts at beginning of year	2018-12-31	$141,718
Interest earned on other investments	2018-12-31	$32,013
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2018-12-31	$891,839
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2018-12-31	$874,889
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-12-31	$-83,099
Net investment gain/loss from pooled separate accounts	2018-12-31	$6,848
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-12-31	No
Was there a failure to transmit to the plan any participant contributions	2018-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2018-12-31	No
Contributions received in cash from employer	2018-12-31	$182,785
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$128,252
Did the plan have assets held for investment	2018-12-31	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	2018-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2018-12-31	Disclaimer
Accountancy firm name	2018-12-31	WEGMANNDAZET
Accountancy firm EIN	2018-12-31	720870824
2017 : KINGSLEY HOUSE INC 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	$507,224
Total loss/gain on sale of assets	2017-12-31	$0
Total of all expenses incurred	2017-12-31	$270,652
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$270,652
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$263,153
Value of total assets at end of year	2017-12-31	$2,330,116
Value of total assets at beginning of year	2017-12-31	$2,093,544
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$0
Total interest from all sources	2017-12-31	$30,284
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
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$200,000
If this is an individual account plan, was there a blackout period	2017-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Contributions received from participants	2017-12-31	$14,784
Participant contributions at end of year	2017-12-31	$0
Participant contributions at beginning of year	2017-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2017-12-31	$51,055
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	$236,572
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$2,330,116
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$2,093,544
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 registered invesment companies (eg mutual funds) at end of year	2017-12-31	$1,313,509
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2017-12-31	$1,095,839
Value of interest in pooled separate accounts at end of year	2017-12-31	$141,718
Value of interest in pooled separate accounts at beginning of year	2017-12-31	$145,884
Interest earned on other investments	2017-12-31	$30,284
Value of interest in common/collective trusts at end of year	2017-12-31	$0
Value of interest in common/collective trusts at beginning of year	2017-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2017-12-31	$874,889
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2017-12-31	$851,821
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2017-12-31	$207,854
Net investment gain/loss from pooled separate accounts	2017-12-31	$5,933
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
Contributions received in cash from employer	2017-12-31	$197,314
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$270,652
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	Unqualified
Accountancy firm name	2017-12-31	WEGMANN DAZET & COMPANY
Accountancy firm EIN	2017-12-31	720870824
2016 : KINGSLEY HOUSE INC 2016 401k financial data
Total income from all sources	2016-12-31	$220,701
Expenses. Total of all expenses incurred	2016-12-31	$100,201
Benefits paid (including direct rollovers)	2016-12-31	$100,201
Total plan assets at end of year	2016-12-31	$2,093,545
Total plan assets at beginning of year	2016-12-31	$1,973,045
Total contributions received or receivable from participants	2016-12-31	$9,642
Other income received	2016-12-31	$102,845
Net income (gross income less expenses)	2016-12-31	$120,500
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$2,093,545
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$1,973,045
Total contributions received or receivable from employer(s)	2016-12-31	$108,214

Form 5500 Responses for KINGSLEY HOUSE INC

2022: KINGSLEY HOUSE INC 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: KINGSLEY HOUSE INC 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: KINGSLEY HOUSE INC 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: KINGSLEY HOUSE INC 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: KINGSLEY HOUSE INC 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	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
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: KINGSLEY HOUSE INC 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: KINGSLEY HOUSE INC 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 – Trust	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

TIAA-CREF (National Association of Insurance Commissioners NAIC id number: 69345 )

Policy contract number

337432

Policy instance

Insurance contract or identification number	337432
Number of Individuals Covered	283
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	Yes
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

TIAA-CREF (National Association of Insurance Commissioners NAIC id number: 69345 )

Policy contract number

337432

Policy instance

Insurance contract or identification number	337432
Number of Individuals Covered	294
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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?	Yes
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

TIAA-CREF (National Association of Insurance Commissioners NAIC id number: 69345 )

Policy contract number

337432

Policy instance

Insurance contract or identification number	337432
Number of Individuals Covered	287
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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?	Yes
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

TIAA-CREF (National Association of Insurance Commissioners NAIC id number: 69345 )

Policy contract number

337432

Policy instance

Insurance contract or identification number	337432
Number of Individuals Covered	282
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	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?	Yes
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No

TIAA-CREF (National Association of Insurance Commissioners NAIC id number: 69345 )

Policy contract number

337432

Policy instance

Insurance contract or identification number	337432
Number of Individuals Covered	271
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	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?	Yes
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No

TIAA-CREF (National Association of Insurance Commissioners NAIC id number: 69345 )

Policy contract number

337432

Policy instance

Insurance contract or identification number	337432
Number of Individuals Covered	251
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	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?	Yes
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	CLOVER NOLA, INC.
Employer identification number (EIN):	720408940
NAIC Classification:	624100
NAIC Description:	Individual and Family Services