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FORM 5500 DATA

Northwest Buffalo Community Health Care Center, Inc. 403(B) Plan

Overview

Plan Information

  • Plan Year01/01/2017 — 12/31/2017
  • Date of Plan01/01/2009
  • Net Assets as of 12/31/2017 $2,863,838
  • Plan Number1
  • Plan Type Single Employer
  • Is the plan collectively bargained? No
  • Did the plan file for an extension of time or the DFVC Program?Yes
  • Plan Funding ArrangementInsurance
  • Plan Benefit ArrangementInsurance

Participant Information as of 12/31/2017

  • Active (Eligible) Participants251
  • Retired or separated participants receiving benefits21
  • Other retired or separated participants entitled to future benefits2
  • Subtotal274
  • Deceased participants whose beneficiaries are receiving or are entitled to receive benefits0
  • Total274
  • Total number of participants as of 01/01/2017211
  • Number of participants with account balances140
  • Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested0

Expenses

  • Total Benefit Payments$0
  • Corrective Distributions$0
  • Administrative Service Providers$0
  • Other Expenses$0
  • Total Expenses$0
  • Total Transfers$0

Sponsor Information

  • Address155 Lawn Avenue
  • CityBuffalo
  • StateNY
  • Zip14207-1618
  • Telephone(716) 875-2904
  • EIN16-1294447
  • Industry Code621399
  • Named AdministratorJoanne Haefner

Audit Information

  • Audit StatusAudited
  • AuditorJeffrey L. Offhaus CPA, LLC
  • Auditor EIN20-2368569
  • Audit Opinion Disclaimer
  • Audit TypeLimited Scope Audit

Benefits Provided Under the Plan

Code Benefit Description
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.
2M Code section 403(b)(7) accounts A 403(b)(7) plan is a tax-deferred retirement plan often available to employees of public schools or non-profit organizations.

Questions and Answers

Question Answer Amount
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? No
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
Were any leases to which the plan was a party in default or classified during the year as uncollectible? No
Were there any nonexempt transactions with any party-in-interest? No
Was this plan covered by a fidelity bond? Yes $300,000
Did the plan have a loss, whether or not reimbursed by the plan's fidelity bond, that was caused by fraud or dishonesty? No
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
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
Did the plan have assets held for investment? Yes
Were any plan transactions or series of transactions in excess of 5% of the current value of plan assets? No
Were all the plan assets either distributed to participants or beneficiaries, transferred to another plan, or brought under the control of the PBGC? No
Has the plan failed to provide any benefit when due under the plan? No
If this is an individual account plan, was there a blackout period? No
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? No

Financials

Income and Expense Statement

Income $1,171,017
Contributions $914,804
Cash Contributions $914,804
Cash from Employers $116,382
Cash from Participants $545,516
Others (including rollovers) $252,906
Noncash Contributions $0
Total Earnings on Investments $253,124
Total Interest $1,437
Interest-Bearing Cash $0
U.S. Government Securities $0
Corporate Debt Instruments $0
Loans (other than to participants) $1,437
Participant Loans $0
Interest from Other Investments $0
Total Dividends $0
Preferred Stock $0
Common Stock $0
Rents $0
Net gain (loss) on sale of assets $0
Aggregate Proceeds $0
Aggregate Carrying Amount $0
Total Unrealized Appreciation (depreciation) of assets $0
Real Estate $0
Other $0
Net investment gain (loss) from common/collective trusts $0
Net investment gain (loss) from pooled separate accounts $0
Net investment gain (loss) from master trust investment accounts $0
Net investment gain (loss) from 103-12 investment entities $0
Net investment gain (loss) from registered investment companies $251,687
Other Income $3,089
Expenses $189,767
Total Benefit Payments $186,181
Directly to participants or beneficiaries, including direct rollovers $186,181
To insurance carriers for the provision of benefits $0
Other Benefit Payment Fees $0
Corrective Distributions $0
Certain deemed distributions of participant loans $0
Interest expense $0
Total Administrative Expenses $3,586
Professional Fees $0
Contract Administrator Fees $3,586
Investment Advisory and management fees $0
Other Administrative Fees $0
Net Income $981,250
Transfers of Assets to this Plan $0
Transfers of Assets from this Plan $0

Asset and Liability Statement

12/31/2017 12/31/2016 Change YOY
Total Assets $2,863,838 $1,882,588 52.12%
Total noninterest-bearing cash $0 $0 0.0%
Receivables $106,386 $85,896 23.85%
Employer Contributions $106,386 $85,896 23.85%
Participant Contributions $0 $0 0.0%
Other Contributions $0 $0 0.0%
General Investments $0 $0 0.0%
Interest-bearing cash $0 $0 0.0%
U.S. Government Securities $0 $0 0.0%
Corporate Debt Instruments $0 $0 0.0%
Preferred $0 $0 0.0%
All Other $0 $0 0.0%
Corporate Stocks $0 $0 0.0%
Preferred $0 $0 0.0%
Common $0 $0 0.0%
Partnership/joint venture interests $0 $0 0.0%
Real estate (other than employer real property) $0 $0 0.0%
Loans (other than to participants) $0 $0 0.0%
Participants Loans $52,482 $35,055 49.71%
Value of interest in common/collective trusts $0 $0 0.0%
Value of interest in pooled separate accounts $0 $0 0.0%
Value of interest in master trust investment accounts $0 $0 0.0%
Value of interest in 103-12 investment entities $0 $0 0.0%
Value of interest in registered investment companies $2,325,184 $1,437,683 61.73%
Value of funds held in insurance co. general account $379,786 $323,954 17.23%
Other Investments $0 $0 0.0%
Employer-related Investments $0 $0 0.0%
Employer Securities $0 $0 0.0%
Employer Real Property $0 $0 0.0%
Buildings and other property used in plan operation $0 $0 0.0%
Total Liabilities $0 $0 0.0%
Benefit Claims Payable (1) $0 $0 0.0%
Operating Payables (1) $0 $0 0.0%
Acquisition Indebtedness (1) $0 $0 0.0%
Other liabilities (1) $0 $0 0.0%
Net Assets $2,863,838 $1,882,588 52.12%

Service Providers

Persons Receiving Only Eligible Indirect Compensation

There is no information on eligible indirect compensation for this plan.

Other Service Providers Receiving Direct or Indirect Compensation

Name Nature of Service Relationship to Plan Sponsor Direct Compensation Paid by Plan Indirect Compensation Paid by Plan Total Compensation
Nationwide Recordkeeping and information management (computing, tabulating, data processing, etc.), Custodial (securities), Other services, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees, Recordkeeping fees, Other fees Custodian $16,778 $0 $16,778
Fsc Securities Corp Other commissions, Securities brokerage commissions and fees Broker $0 $12,740 $12,740
Security Administrators, Inc. Recordkeeping and information management (computing, tabulating, data processing, etc.), Recordkeeping fees TPA $5,665 $407 $6,072
Total $22,443 $13,147 $35,590

Indirect Compensation

There are no service providers with indirect compensation listed for this plan.

Service Providers Who Fail or Refuse to Provide Information

There are no service providers who failed or refused to provide information.

Termination Information on Accountants and Enrolled Actuaries

There is no termination information for this plan.

Investments

Investments

No investments information available for this plan.

Insurance Information

Insurance Information

Insurance Carrier Summary Persons Covered
Nationwide Life Insurance Company 140
EIN 31-4156830
Industry Code 66869
Contract Number GAP-B2-KB2D
Contract Year 01/01/2017 — 12/31/2017
Value in General Account at Year End $0
Value in Separate Accounts at Year End $0
Insurance Fees and Commissions $691
Persons Receiving Commissions and Fees
Agent/Broker Organization Code Commissions Paid Fees Paid Purpose of Fees Paid
Fsc Securities Corp 2300 Windy Ridge Pkwy Ste 1100 Atlanda, GA 30339 Agent or Broker other than Insurance $691 $0
Allocated Funds
Type of Contract Unspecified
Basis of premium rates
Premiums paid to carrier $0
Premiums due but unpaid at the end of the year $0
If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, enter amount $0
Specify the nature of the costs
Unallocated Funds
Type of Contract Guaranteed Investment
Balance at the end of the previous year $0
Additions $461,685
Contributions Deposited during the year $46,972
Dividends and credits $0
Interest credited during the year $2,572
Transferred from separate account $0
Other $412,141
Total of Balance and Additions $461,685
Deductions $85,380
Disbursed from fund to pay benefits or purchase annuities during the year $69,564
Administration charge made by carrier $464
Transferred to Separate Account $9,425
Other $5,927
Balance at the end of the current year $376,305
Nationwide Life Insurance Company 0
EIN 31-4156830
Industry Code 66869
Contract Number GAP-B2-CA3B
Contract Year 01/01/2017 — 12/31/2017
Value in General Account at Year End $0
Value in Separate Accounts at Year End $0
Insurance Fees and Commissions $402
Persons Receiving Commissions and Fees
Agent/Broker Organization Code Commissions Paid Fees Paid Purpose of Fees Paid
Fsc Securities Corp 2300 Windy Ridge Pkwy Ste 1100 Atlanta, GA 30339 Agent or Broker other than Insurance $402 $0
Allocated Funds
Type of Contract Unspecified
Basis of premium rates
Premiums paid to carrier $0
Premiums due but unpaid at the end of the year $0
If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, enter amount $0
Specify the nature of the costs
Unallocated Funds
Type of Contract Guaranteed Investment
Balance at the end of the previous year $320,819
Additions $84,492
Contributions Deposited during the year $49,964
Dividends and credits $0
Interest credited during the year $1,808
Transferred from separate account $0
Other $32,720
Total of Balance and Additions $405,311
Deductions $405,311
Disbursed from fund to pay benefits or purchase annuities during the year $404,281
Administration charge made by carrier $612
Transferred to Separate Account $0
Other $418
Balance at the end of the current year $0