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FORM 5500 DATA

The Richland Hospital, Inc. Money Purchase Plan

Overview

Plan Information

  • Plan Year01/01/2015 — 12/31/2015
  • Date of Plan05/01/1970
  • Net Assets as of 12/31/2015 $13,189,596
  • 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 Trust
  • Plan Benefit ArrangementInsurance Trust

Participant Information as of 12/31/2015

  • Active (Eligible) Participants240
  • Retired or separated participants receiving benefits5
  • Other retired or separated participants entitled to future benefits49
  • Subtotal294
  • Deceased participants whose beneficiaries are receiving or are entitled to receive benefits0
  • Total294
  • Total number of participants as of 01/01/2015297
  • Number of participants with account balances291
  • 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

  • Address333 East Second Street
  • CityRichland Center
  • StateWI
  • Zip53581
  • Telephone(608) 647-6321
  • EIN39-0808498
  • Industry Code622000
  • Named AdministratorRhonda Sutton

Plan Administrator Information

  • Administrator NameThe Richland Hospital, Inc.
  • Address333 East Second Street
  • CityRichland Center
  • StateWI
  • Zip53581
  • Telephone(608) 647-6321
  • Administrator EIN39-0808498

Audit Information

  • Audit StatusAudited
  • AuditorWipfli LLP
  • Auditor EIN39-0758449
  • Audit Opinion Disclaimer
  • Audit TypeLimited Scope Audit

Benefits Provided Under the Plan

Code Benefit Description
2C Money purchase A pension plan, other than a target benefit plan that requires a fixed percentage of compensation to be contributed to each eligible employee.
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.
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.
3D 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.

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 $1,000,000
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? Yes
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? Yes

Financials

Income and Expense Statement

Income $524,616
Contributions $561,575
Cash Contributions $561,575
Cash from Employers $561,575
Cash from Participants $0
Others (including rollovers) $0
Noncash Contributions $0
Total Earnings on Investments $-80,287
Total Interest $0
Interest-Bearing Cash $0
U.S. Government Securities $0
Corporate Debt Instruments $0
Loans (other than to participants) $0
Participant Loans $0
Interest from Other Investments $0
Total Dividends $561,232
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 $-641,519
Other Income $43,328
Expenses $278,425
Total Benefit Payments $276,641
Directly to participants or beneficiaries, including direct rollovers $276,641
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 $1,784
Professional Fees $0
Contract Administrator Fees $1,784
Investment Advisory and management fees $0
Other Administrative Fees $0
Net Income $246,191
Transfers of Assets to this Plan $0
Transfers of Assets from this Plan $0

Asset and Liability Statement

12/31/2015 12/31/2014 Change YOY
Total Assets $13,189,596 $12,966,981 1.72%
Total noninterest-bearing cash $0 $0 0.0%
Receivables $45,518 $62,041 -26.63%
Employer Contributions $0 $0 0.0%
Participant Contributions $0 $0 0.0%
Other Contributions $45,518 $62,041 -26.63%
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 $0 $0 0.0%
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 $10,650,985 $10,736,278 -0.79%
Value of funds held in insurance co. general account $2,493,093 $2,168,662 14.96%
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 $23,576 -100.00%
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 $23,576 -100.00%
Net Assets $13,189,596 $12,943,405 1.90%

Service Providers

Persons Receiving Only Eligible Indirect Compensation

  • Principal Life Insurance Company

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
Vsr Financial Services Inc Other services, Other commissions, Other fees Other Services $0 $13,144 $13,144
Principal Life Insurance Company Contract Administrator, Direct payment from the plan, Recordkeeping fees Contract Administrator $1,783 $0 $1,783
Wilshire Associates Incorporated Investment advisory (plan), Other investment fees and expenses Investment Advisory $0 $0 $0
Total $1,783 $13,144 $14,927

Indirect Compensation

Name Source of Indirect Compensation* Nature of Service Description of Indirect Compensation Indirect Compensation Paid by Plan
Wilshire Associates Incorporated Principal Life Insurance Company Investment advisory (plan), Other investment fees and expenses 2 Basis Points Annually On Total Assets Up To $10 Billion, and 1 Basis Point for Assets Greater Than $10 Billion, and 0.50 Basis Points (Starting January 1, 2014) for Assets Greater Than $17 Billion In Wilshire's 3(21) Investment Fiduciary Service $0
Vsr Financial Services Inc Principal Life Insurance Company Other services, Other commissions, Other fees Commissions and Referral/Service Fee $13,144
*As outlined by the Form 5500 Instructions for service providers with indirect compensation.

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
Principal Life Insurance Company 294
EIN 42-0127290
Industry Code 61271
Contract Number 441462
Contract Year 01/01/2015 — 12/31/2015
Value in General Account at Year End $0
Value in Separate Accounts at Year End $0
Insurance Fees and Commissions $2,679
Persons Receiving Commissions and Fees
Agent/Broker Organization Code Commissions Paid Fees Paid Purpose of Fees Paid
Vsr Financial Services Inc 8620 W 110th St Overland Park, KS 66210 -4036 Insurance Agent or Broker $2,679 $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 CUSTODIAL GUARANTEED FUND CONTRACT
Balance at the end of the previous year $2,168,662
Additions $432,630
Contributions Deposited during the year $35,276
Dividends and credits $0
Interest credited during the year $43,326
Transferred from separate account $0
Other $354,028
Total of Balance and Additions $2,601,292
Deductions $108,199
Disbursed from fund to pay benefits or purchase annuities during the year $97,512
Administration charge made by carrier $321
Transferred to Separate Account $0
Other $10,366
Balance at the end of the current year $2,493,093