401k Plan data: POLYFORM TAX DEFERRED SAVINGS PLAN plan

POLYFORM TAX DEFERRED SAVINGS PLAN 401k Plan overview

Plan Name	POLYFORM TAX DEFERRED SAVINGS PLAN
Plan identification number	001

POLYFORM TAX DEFERRED SAVINGS 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.
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.

401k Sponsoring company profile

POLYFORM U.S., LTD. has sponsored the creation of one or more 401k plans.

Company Name: POLYFORM U.S., LTD.

Employer identification number (EIN): 911078061

NAIC Classification: 326100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan POLYFORM TAX DEFERRED SAVINGS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2021-01-01 VALERIE EDWARDS 2022-10-18 VALERIE EDWARDS 2022-10-18
001 2020-01-01 VALERIE EDWARDS 2021-10-12
001 2019-01-01 VALERIE EDWARDS 2020-10-09 VALERIE EDWARDS 2020-10-09
001 2018-01-01 VALERIE 2019-05-30
001 2017-01-01 DIANA A. TRISTANI GAZTAMBIDE 2018-07-06 DIANA A. TRISTANI GAZTAMBIDE 2018-07-06
001 2016-01-01 DIANA A. TRISTANI GAZTAMBIDE 2017-07-21 DIANA A. TRISTANI GAZTAMBIDE 2017-07-21
001 2015-01-01 DIANA TRISTANI-GAZTAMBIDE 2016-05-20
001 2014-01-01 DIANA TRISTANI GAZTAMBIDE DIANA TRISTANI GAZTAMBIDE 2015-07-29
001 2013-01-01 DIANA TRISTANI GAZTAMBIDE DIANA TRISTANI GAZTAMBIDE 2014-07-15
001 2012-01-01 DIANA TRISTANI GAZTAMBIDE DIANA TRISTANI GAZTAMBIDE 2013-07-26
001 2011-01-01 DIANA TRISTANIGAZTAMBID 2012-02-02 DIANA TRISTANIGAZTAMBID 2012-02-02
001 2010-01-01 DIANA TRISTANIGAZTAMBID 2011-02-02 DIANA TRISTANIGAZTAMBID 2011-02-02

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2021-01-01	VALERIE EDWARDS	2022-10-18	VALERIE EDWARDS	2022-10-18
001	2020-01-01	VALERIE EDWARDS	2021-10-12
001	2019-01-01	VALERIE EDWARDS	2020-10-09	VALERIE EDWARDS	2020-10-09
001	2018-01-01	VALERIE	2019-05-30
001	2017-01-01	DIANA A. TRISTANI GAZTAMBIDE	2018-07-06	DIANA A. TRISTANI GAZTAMBIDE	2018-07-06
001	2016-01-01	DIANA A. TRISTANI GAZTAMBIDE	2017-07-21	DIANA A. TRISTANI GAZTAMBIDE	2017-07-21
001	2015-01-01	DIANA TRISTANI-GAZTAMBIDE	2016-05-20
001	2014-01-01	DIANA TRISTANI GAZTAMBIDE		DIANA TRISTANI GAZTAMBIDE	2015-07-29
001	2013-01-01	DIANA TRISTANI GAZTAMBIDE		DIANA TRISTANI GAZTAMBIDE	2014-07-15
001	2012-01-01	DIANA TRISTANI GAZTAMBIDE		DIANA TRISTANI GAZTAMBIDE	2013-07-26
001	2011-01-01	DIANA TRISTANIGAZTAMBID	2012-02-02	DIANA TRISTANIGAZTAMBID	2012-02-02
001	2010-01-01	DIANA TRISTANIGAZTAMBID	2011-02-02	DIANA TRISTANIGAZTAMBID	2011-02-02

Plan Statistics for POLYFORM TAX DEFERRED SAVINGS PLAN

401k plan membership statisitcs for POLYFORM TAX DEFERRED SAVINGS PLAN

Measure Date Value
2014: POLYFORM TAX DEFERRED SAVINGS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 37
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 34
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 3
Total of all active and inactive participants 2014-01-01 37
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 37
Number of participants with account balances 2014-01-01 28
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 1
2013: POLYFORM TAX DEFERRED SAVINGS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 38
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 37
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 1
Total of all active and inactive participants 2013-01-01 38
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 38
Number of participants with account balances 2013-01-01 28
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: POLYFORM TAX DEFERRED SAVINGS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 38
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 40
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 40
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 40
Number of participants with account balances 2012-01-01 40
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0

Measure	Date	Value
2014: POLYFORM TAX DEFERRED SAVINGS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	37
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	34
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	3
Total of all active and inactive participants	2014-01-01	37
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	37
Number of participants with account balances	2014-01-01	28
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	1
2013: POLYFORM TAX DEFERRED SAVINGS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	38
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	37
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	1
Total of all active and inactive participants	2013-01-01	38
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	38
Number of participants with account balances	2013-01-01	28
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: POLYFORM TAX DEFERRED SAVINGS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	38
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	40
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	40
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	40
Number of participants with account balances	2012-01-01	40
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0

Financial Data on POLYFORM TAX DEFERRED SAVINGS PLAN

Measure	Date	Value
2014 : POLYFORM TAX DEFERRED SAVINGS PLAN 2014 401k financial data
Transfers to/from the plan	2014-12-31	$0
Total income from all sources	2014-12-31	$382,801
Expenses. Total of all expenses incurred	2014-12-31	$73,632
Benefits paid (including direct rollovers)	2014-12-31	$66,293
Total plan assets at end of year	2014-12-31	$2,958,729
Total plan assets at beginning of year	2014-12-31	$2,649,560
Value of fidelity bond covering the plan	2014-12-31	$1,000,000
Total contributions received or receivable from participants	2014-12-31	$121,554
Expenses. Other expenses not covered elsewhere	2014-12-31	$290
Contributions received from other sources (not participants or employers)	2014-12-31	$93,054
Other income received	2014-12-31	$134,282
Net income (gross income less expenses)	2014-12-31	$309,169
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$2,958,729
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$2,649,560
Assets. Value of participant loans	2014-12-31	$52,865
Total contributions received or receivable from employer(s)	2014-12-31	$33,911
Value of certain deemed distributions of participant loans	2014-12-31	$0
Value of corrective distributions	2014-12-31	$7,049
Funding deficiency by the employer to the plan for this plan year	2014-12-31	$0
Minimum employer required contribution for this plan year	2014-12-31	$0
Amount contributed by the employer to the plan for this plan year	2014-12-31	$0
2013 : POLYFORM TAX DEFERRED SAVINGS PLAN 2013 401k financial data
Transfers to/from the plan	2013-12-31	$0
Total income from all sources	2013-12-31	$369,253
Expenses. Total of all expenses incurred	2013-12-31	$22,446
Benefits paid (including direct rollovers)	2013-12-31	$22,261
Total plan assets at end of year	2013-12-31	$2,649,560
Total plan assets at beginning of year	2013-12-31	$2,302,753
Value of fidelity bond covering the plan	2013-12-31	$1,000,000
Total contributions received or receivable from participants	2013-12-31	$124,560
Expenses. Other expenses not covered elsewhere	2013-12-31	$185
Contributions received from other sources (not participants or employers)	2013-12-31	$0
Other income received	2013-12-31	$210,113
Net income (gross income less expenses)	2013-12-31	$346,807
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$2,649,560
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$2,302,753
Assets. Value of participant loans	2013-12-31	$64,705
Total contributions received or receivable from employer(s)	2013-12-31	$34,580
Value of certain deemed distributions of participant loans	2013-12-31	$0
Value of corrective distributions	2013-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2013-12-31	$0
Minimum employer required contribution for this plan year	2013-12-31	$0
Amount contributed by the employer to the plan for this plan year	2013-12-31	$0
2012 : POLYFORM TAX DEFERRED SAVINGS PLAN 2012 401k financial data
Transfers to/from the plan	2012-12-31	$0
Total income from all sources	2012-12-31	$327,665
Expenses. Total of all expenses incurred	2012-12-31	$322,411
Benefits paid (including direct rollovers)	2012-12-31	$320,762
Total plan assets at end of year	2012-12-31	$2,302,753
Total plan assets at beginning of year	2012-12-31	$2,297,499
Value of fidelity bond covering the plan	2012-12-31	$1,000,000
Total contributions received or receivable from participants	2012-12-31	$104,061
Expenses. Other expenses not covered elsewhere	2012-12-31	$1,649
Contributions received from other sources (not participants or employers)	2012-12-31	$0
Other income received	2012-12-31	$191,715
Net income (gross income less expenses)	2012-12-31	$5,254
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$2,302,753
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$2,297,499
Assets. Value of participant loans	2012-12-31	$71,753
Total contributions received or receivable from employer(s)	2012-12-31	$31,889
Value of certain deemed distributions of participant loans	2012-12-31	$0
Value of corrective distributions	2012-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2012-12-31	$0
Minimum employer required contribution for this plan year	2012-12-31	$0
Amount contributed by the employer to the plan for this plan year	2012-12-31	$0

Form 5500 Responses for POLYFORM TAX DEFERRED SAVINGS PLAN

2014: POLYFORM TAX DEFERRED SAVINGS 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
2013: POLYFORM TAX DEFERRED SAVINGS 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
2012: POLYFORM TAX DEFERRED SAVINGS 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 funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-828464

Policy instance

Insurance contract or identification number	GA-828464
Number of Individuals Covered	28
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12,121
Total amount of fees paid to insurance company	USD $0
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 $12,121
Insurance broker organization code?	3
Insurance broker name	LPL FINANCIAL CORPORATION

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-828464

Policy instance

Insurance contract or identification number	GA-828464
Number of Individuals Covered	28
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $10,443
Total amount of fees paid to insurance company	USD $54
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 $10,443
Insurance broker organization code?	3
Amount paid for insurance broker fees	54
Additional information about fees paid to insurance broker	SALES/MARKETING
Insurance broker name	LPL FINANCIAL LLC

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-828464

Policy instance

Insurance contract or identification number	GA-828464
Number of Individuals Covered	40
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $7,168
Total amount of fees paid to insurance company	USD $49
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 $7,168
Insurance broker organization code?	3
Amount paid for insurance broker fees	49
Additional information about fees paid to insurance broker	SALES/MARKETING
Insurance broker name	LPL FINANCIAL LLC

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Company Name:	POLYFORM U.S., LTD.
Employer identification number (EIN):	911078061
NAIC Classification:	326100