401k Plan data: CANNATAS SUPERMARKET, INC. EMPLOYEE HEALTH INSURANCE PLAN plan

CANNATAS SUPERMARKET, INC. EMPLOYEE HEALTH INSURANCE PLAN 401k Plan overview

Plan Name	CANNATAS SUPERMARKET, INC. EMPLOYEE HEALTH INSURANCE PLAN
Plan identification number	501

CANNATAS SUPERMARKET, INC. EMPLOYEE HEALTH INSURANCE PLAN Benefits

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

401k Sponsoring company profile

CANNATA'S SUPERMARKET, INC. has sponsored the creation of one or more 401k plans.

Company Name: CANNATA'S SUPERMARKET, INC.

Employer identification number (EIN): 720524089

NAIC Classification: 445110
NAIC Description: Supermarkets and Other Grocery (except Convenience) Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CANNATAS SUPERMARKET, INC. EMPLOYEE HEALTH INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-03-01 VINCENT CANNATA

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2016-03-01	VINCENT CANNATA

Plan Statistics for CANNATAS SUPERMARKET, INC. EMPLOYEE HEALTH INSURANCE PLAN

401k plan membership statisitcs for CANNATAS SUPERMARKET, INC. EMPLOYEE HEALTH INSURANCE PLAN

Measure Date Value
2016: CANNATAS SUPERMARKET, INC. EMPLOYEE HEALTH INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-03-01 118
Total number of active participants reported on line 7a of the Form 5500 2016-03-01 97
Number of retired or separated participants receiving benefits 2016-03-01 0
Number of other retired or separated participants entitled to future benefits 2016-03-01 0
Total of all active and inactive participants 2016-03-01 97
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-03-01 0

Measure	Date	Value
2016: CANNATAS SUPERMARKET, INC. EMPLOYEE HEALTH INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-03-01	118
Total number of active participants reported on line 7a of the Form 5500	2016-03-01	97
Number of retired or separated participants receiving benefits	2016-03-01	0
Number of other retired or separated participants entitled to future benefits	2016-03-01	0
Total of all active and inactive participants	2016-03-01	97
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-03-01	0

Form 5500 Responses for CANNATAS SUPERMARKET, INC. EMPLOYEE HEALTH INSURANCE PLAN

2016: CANNATAS SUPERMARKET, INC. EMPLOYEE HEALTH INSURANCE PLAN 2016 form 5500 responses
2016-03-01	Type of plan entity	Single employer plan
2016-03-01	Submission has been amended	No
2016-03-01	This submission is the final filing	No
2016-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-03-01	Plan is a collectively bargained plan	No
2016-03-01	Plan funding arrangement – Insurance	Yes
2016-03-01	Plan benefit arrangement – Insurance	Yes

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Company Name:	CANNATA'S SUPERMARKET, INC.
Employer identification number (EIN):	720524089
NAIC Classification:	445110
NAIC Description:	Supermarkets and Other Grocery (except Convenience) Stores