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Overview

Plan Information

  • Plan Year10/01/2008 — 09/30/2009
  • Date of Plan10/01/1997
  • Net Assets as of 09/30/2009 $325,431
  • 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? No

Participant Information as of 09/30/2009

  • Active (Eligible) Participants90
  • Retired or separated participants receiving benefits0
  • Other retired or separated participants entitled to future benefits5
  • Subtotal95
  • Deceased participants whose beneficiaries are receiving or are entitled to receive benefits0
  • Total95
  • Total number of participants as of 10/01/2008106
  • Number of participants with account balances16
  • Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested40
  • Number of participants required to be reported on Schedule SSA2

Expenses

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

Sponsor Information

  • Address655 Peddycord Road
  • CityKernersville
  • StateNC
  • Zip27284-8351
  • Telephone(336) 727-4534
  • EIN56-1542985
  • Industry Code238100
  • Named Administrator, ) ) , C Vip
  • Named Plan SponsorIsn^^' Iuaf\(3

Plan Administrator Information

  • Administrator NameSAME
  • Administrator EIN

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.
3E Prototype plan A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion or notification letter; and under which a separate funding medium (for example, a separate trust or custodial account) is established for the use of each adopting employer.

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? No
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 at any time hold 20% or more of its assets in any single security, debt, mortgage, parcel of real estate, or partnership/joint venture interest? No $0
Are you claiming a waiver of the annual examination and report of an independent qualified public accountant (IQPA) under 29 CFR 2520.104-46? Yes
Were all the plan assets either distributed to participants or beneficiaries, transferred to another plan, or brought under the control of the PBGC? No

Financials

Income and Expense Statement

Income $23,189
Contributions $0
Cash Contributions $47,026
Cash from Employers $3,287
Cash from Participants $43,739
Others (including rollovers) $0
Noncash Contributions $0
Other Income $0
Expenses $54,887
Total Benefit Payments $44,757
Corrective Distributions $1,321
Certain deemed distributions of participant loans $8,512
Other Expenses $297
Net Income $-31,698
Transfers of Assets to (from) this Plan $0

Asset and Liability Statement

09/30/2009 09/30/2008 Change YOY
Total Assets $325,431 $357,129 -8.88%
Total Liabilities $0 $0 0.0%
Net Assets $325,431 $357,129 -8.88%

Specific Assets Statement

Held? Amount
Total Specific Assets No $62,613
Partnership/joint venture interests Yes $0
Employer Real Property Yes $0
Real Estate Yes $0
Employer Securities Yes $0
Participant Loans No $62,613
Loans (other than to participants) Yes $0
Tangible Personal Property Yes $0

Service Providers

Service Providers

There are no service providers listed for this plan.

Investments

Investments

Name of Investment Investment Manager Type of Investment Dollar Value
Kutupfllinds Series Accountii of Gw Great-West Life & Annuity Insurance DFE: Pooled Separate Account $183,773
Total $183,773

Insurance Information

Insurance Information

Insurance Carrier Summary Persons Covered
Grfat West Retirement Services 16
EIN 84-0467907
Industry Code 68322
Contract Number 93385601
Contract Year 10/01/2008 — 09/30/2009
Value in General Account at Year End $79,045
Value in Separate Accounts at Year End $183,773
Insurance Fees and Commissions $0
Persons Receiving Commissions and Fees There are no brokers listed for this plan.
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
Balance at the end of the previous year $29,271
Additions $128,428
Contributions Deposited during the year $14,494
Dividends and credits $0
Interest credited during the year $2,460
Transferred from separate account $107,846
Other $3,628
Total of Balance and Additions $0
Deductions $78,654
Disbursed from fund to pay benefits or purchase annuities during the year $78,654
Administration charge made by carrier $0
Transferred to Separate Account $0
Other $0
Balance at the end of the current year $79,045