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Company:
Clover Holdings Group, LLC

Plan:
Clover Holdings 401k Plan
 
Form 5500 | Basic Information
Plan Information
Plan Year 01/01/2012 — 12/31/2012
Effective Date of Plan 01/01/1999
Net Assets as of 12/31/2012 $21,003,494
Plan Number 1
Plan Type Single Employer
Is the plan collectively bargained? No
Did the plan file for an extension of time or the DFVC Program? Yes
Report Description This is an amended report.
Plan Funding Arrangement Insurance
Trust
Plan Benefit Arrangement Insurance
Trust

Participant Information as of 12/31/2012
Active (Eligible) Participants 1,652
Retired or separated participants receiving benefits 0
Other retired or separated participants entitled to future benefits 60
Subtotal 1,712
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 0
Total 1,712
Total number of participants as of 01/01/2012 1,790
Number of participants with account balances 1,148
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 299

Plan Sponsor Information
Address 4200 Columbus St
Ottawa, IL 61350 -9538
Telephone (815) 431-8100
EIN 36-4375236
Industry Code 334110
Named Administrator Cheryl Terry
Named Plan Sponsor Cheryl Terry

Audit Information
Audit Status Audited
Auditor Fgmk, LLC
Auditor EIN 36-2929601
Audit Opinion Disclaimer
Audit Type Limited Scope Audit

Benefits Provided Under the Plan
Code Benefit Description
2E Profit-sharing A defined contribution plan that allows employer discretionary contributions. These plans often contain a 401(k) feature.
2F ERISA section 404(c) Plan This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
2G 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.
2J 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.
2K 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 contributions 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.
2T Participant-directed Account Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.

  Question Answer Amount
1. During the plan year did the employer fail to transmit to the plan any participant contributions within the time period described in 29 CFT 2510.3-102? Yes $228,382
2. Were any loans by the plan or fixed income obligations due the plan in default as of the close of plan year or classified during the year as uncollectible? Disregard participant loans secured by participant's account balance. No  
3. Were any leases to which the plan was a party in default or classified during the year as uncollectible? No  
4. Were there any nonexempt transactions with any party-in-interest? No  
5. Was this plan covered by a fidelity bond? Yes $10,000,000
6. Did the plan have a loss, whether or not reimbursed by the plan's fidelity bond, that was caused by fraud or dishonesty? No  
7. Did the plan hold any assets whose current value was neither readily determinable on an established market nor set by an independent third party appraiser? No  
8. Did the plan receive any noncash contributions whose value was neither readily determinable on an established market nor set by an independent third party appraiser? No  
9. Did the plan have assets held for investment? Yes  
10. Were any plan transactions or series of transactions in excess of 5% of the current value of plan assets? No  
11. Were all the plan assets either distributed to participants or beneficiaries, transferred to another plan, or brought under the control of the PBGC? No  
12. Has the plan failed to provide any benefit when due under the plan? No  
13. If this is an individual account plan, was there a blackout period? No  
14. If there was a blackout period, have you either provided the required notice or one of the exceptions to providing the notice applied under 29 CFR 2520.101-3?