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FORM 5500 DATA

Ida County Iowa Community Hospital Inc. d/b/a Horn Memorial Hospital Tax Deferred Annuity Plan

Overview

Plan Information

  • Plan Year01/01/2017 — 12/31/2017
  • Date of Plan01/01/2009
  • Net Assets as of 12/31/2017 $5,113,190
  • Plan Number2
  • 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 ArrangementInsurance
  • Plan Benefit ArrangementInsurance Trust

Participant Information as of 12/31/2017

  • Active (Eligible) Participants206
  • Retired or separated participants receiving benefits2
  • Other retired or separated participants entitled to future benefits35
  • Subtotal243
  • Deceased participants whose beneficiaries are receiving or are entitled to receive benefits0
  • Total243
  • Total number of participants as of 01/01/2017240
  • Number of participants with account balances198
  • 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

  • Address701 E 2nd St
  • CityIda Grove
  • StateIA
  • Zip51445-1669
  • Telephone(712) 364-3311
  • EIN42-0843389
  • Industry Code622000
  • Named AdministratorGlen Winekauf

Audit Information

  • Audit StatusAudited
  • AuditorGronewold, Bell, Kyhnn & Co. P.C.
  • Auditor EIN42-1206169
  • 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.
2L Code section 403(b)(1) arrangement A 403(b) plan, also known as a tax-sheltered annuity (TSA) plan, is a retirement plan for certain employees of public schools, employees of certain tax-exempt organizations, and certain ministers.
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.

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 $500,000
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 $1,099,189
Contributions $450,439
Cash Contributions $450,439
Cash from Employers $0
Cash from Participants $450,439
Others (including rollovers) $0
Noncash Contributions $0
Total Earnings on Investments $648,750
Total Interest $41,933
Interest-Bearing Cash $0
U.S. Government Securities $0
Corporate Debt Instruments $0
Loans (other than to participants) $0
Participant Loans $3,375
Interest from Other Investments $38,558
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 $606,817
Other Income $0
Expenses $212,188
Total Benefit Payments $211,131
Directly to participants or beneficiaries, including direct rollovers $211,131
To insurance carriers for the provision of benefits $0
Other Benefit Payment Fees $0
Corrective Distributions $656
Certain deemed distributions of participant loans $0
Interest expense $0
Total Administrative Expenses $401
Professional Fees $0
Contract Administrator Fees $401
Investment Advisory and management fees $0
Other Administrative Fees $0
Net Income $887,001
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 $5,113,190 $4,226,189 20.99%
Total noninterest-bearing cash $0 $0 0.0%
Receivables $17,667 $15,326 15.27%
Employer Contributions $0 $0 0.0%
Participant Contributions $17,667 $15,326 15.27%
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 $79,044 $82,921 -4.68%
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 $4,061,298 $3,147,751 29.02%
Value of funds held in insurance co. general account $955,181 $980,191 -2.55%
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 $5,113,190 $4,226,189 20.99%

Service Providers

Persons Receiving Only Eligible Indirect Compensation

  • American United Life Insurance Co

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
American United Life Insurance Co Participant loan processing, Direct payment from the plan, Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees, Insurance mortality and expense charge, Other insurance wrap fees, Participant communication NONE $507 $17,747 $18,254
Total $507 $17,747 $18,254

Indirect Compensation

Name Source of Indirect Compensation* Nature of Service Description of Indirect Compensation Indirect Compensation Paid by Plan
American United Life Insurance Co American United Life Insurance Co Insurance mortality and expense charge, Other insurance wrap fees Asset Charge $17,747
American United Life Insurance Co Allianz Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co American Century Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co American Funds Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co Columbia Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co DFA Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co Fidelity Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co Fifth Third Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co Franklin/Templeton Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co Invesco Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co Janus Henderson Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co MFS Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co Pimco Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co Pioneer Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co Prudential Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co Russell Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co State Street Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co T. Rowe Price Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co Thornburg Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
American United Life Insurance Co Touchstone Investment management fees paid indirectly by plan, Shareholder servicing fees, Sub-transfer agency fees, Distribution (12b-1) fees Revenue Sharing Formula - See Attached $0
*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

Name of Investment Investment Manager Type of Investment Dollar Value
Separate Account II American United Life Insurance Co DFE: Pooled Separate Account $4,061,298
Total $4,061,298

Insurance Information

Insurance Information

Insurance Carrier Summary Persons Covered
American United Life Insurance Company 198
EIN 35-0145825
Industry Code 60895
Contract Number G93006
Contract Year 01/01/2017 — 12/31/2017
Value in General Account at Year End $955,181
Value in Separate Accounts at Year End $4,061,298
Insurance Fees and Commissions $9,432
Persons Receiving Commissions and Fees
Agent/Broker Organization Code Commissions Paid Fees Paid Purpose of Fees Paid
Northwestern Mutual Investment 611 East Wisconsin Ave Milwaukee, WI 53202 Insurance Agent or Broker $6,318 $0 N/A
Gallagher Ben Services Inc. Po Box 40948 Indianapolis, IN 46240 Insurance Agent or Broker $0 $3,114 N/A
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 GROUP ANNUITY CONTRACT
Balance at the end of the previous year $980,191
Additions $149,486
Contributions Deposited during the year $57,179
Dividends and credits $0
Interest credited during the year $38,558
Transferred from separate account $40,160
Other $13,589
Total of Balance and Additions $1,129,677
Deductions $174,496
Disbursed from fund to pay benefits or purchase annuities during the year $112,369
Administration charge made by carrier $83
Transferred to Separate Account $58,755
Other $3,289
Balance at the end of the current year $955,181