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FORM 5500 DATA

Tribal Health Retirement Savings Plan

Overview

Plan Information

  • Plan Year01/01/2017 — 12/31/2017
  • Date of Plan01/01/1995
  • Net Assets as of 12/31/2017 $2,027,298
  • 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 12/31/2017

  • Active (Eligible) Participants157
  • Retired or separated participants receiving benefits0
  • Other retired or separated participants entitled to future benefits35
  • Subtotal192
  • Deceased participants whose beneficiaries are receiving or are entitled to receive benefits0
  • Total192
  • Total number of participants as of 01/01/2017175
  • Number of participants with account balances153
  • Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested4

Expenses

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

Sponsor Information

  • Address925 Bevins Court
  • CityLakeport
  • StateCA
  • Zip95453
  • Telephone(707) 263-8382
  • EIN94-2847137
  • Industry Code621900

Audit Information

  • Audit StatusAudited
  • AuditorBong Hillberg Lewis Fischesser LLP
  • Auditor EIN45-4806875
  • Audit Opinion Disclaimer
  • Audit TypeLimited Scope Audit

Benefits Provided Under the Plan

Code Benefit Description
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.
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.
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.

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 $150,000
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 $811,685
Contributions $591,501
Cash Contributions $591,501
Cash from Employers $115,360
Cash from Participants $455,537
Others (including rollovers) $20,604
Noncash Contributions $0
Total Earnings on Investments $219,549
Total Interest $3,871
Interest-Bearing Cash $0
U.S. Government Securities $0
Corporate Debt Instruments $0
Loans (other than to participants) $0
Participant Loans $3,003
Interest from Other Investments $868
Total Dividends $29,961
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 $185,717
Other Income $635
Expenses $134,686
Total Benefit Payments $117,700
Directly to participants or beneficiaries, including direct rollovers $117,700
To insurance carriers for the provision of benefits $0
Other Benefit Payment Fees $0
Corrective Distributions $2,177
Certain deemed distributions of participant loans $0
Interest expense $0
Total Administrative Expenses $14,809
Professional Fees $10,768
Contract Administrator Fees $4,041
Investment Advisory and management fees $0
Other Administrative Fees $0
Net Income $676,999
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 $2,027,298 $1,350,376 50.13%
Total noninterest-bearing cash $0 $0 0.0%
Receivables $1,475 $0 0.0%
Employer Contributions $1,475 $0 0.0%
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 $57,392 $69,258 -17.13%
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 $1,808,790 $1,281,118 41.19%
Value of funds held in insurance co. general account $159,641 $0 0.0%
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 $77 -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 $77 -100.00%
Net Assets $2,027,298 $1,350,299 50.14%

Service Providers

Persons Receiving Only Eligible Indirect Compensation

  • Lincoln National Corporation

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
Principal Life Insurance Company Contract Administrator, Participant loan processing, Direct payment from the plan, Recordkeeping fees Contract Administrator $11,775 $0 $11,775
Bidwell Consulting Services, Inc. Plan Administrator TPA $10,768 $0 $10,768
Lincoln National Corporation Contract Administrator Service Provider $650 $0 $650
Total $23,193 $0 $23,193

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

Name of Investment Investment Manager Type of Investment Dollar Value
Fixed Account Lincoln National Life Insurance Co DFE: Pooled Separate Account $52,785
Lvip Managed Risk Profile 2020 Lincoln National Life Insurance Co DFE: Pooled Separate Account $42,295
Fixed Account Lincoln National Life Insurance Co DFE: Pooled Separate Account $26,470
Lvip Dimensional U.S. Core Equity 1 Lincoln National Life Insurance Co DFE: Pooled Separate Account $25,276
Lvip Ssga Glbl Tactical Alloctn Mgd Lincoln National Life Insurance Co DFE: Pooled Separate Account $24,812
American Funds Growth Lincoln National Life Insurance Co DFE: Pooled Separate Account $14,950
Delaware Vip Diversified Income Lincoln National Life Insurance Co DFE: Pooled Separate Account $14,600
American Funds Growth - Income Lincoln National Life Insurance Co DFE: Pooled Separate Account $10,854
Lvip Ssga Emerging Markets 100 Lincoln National Life Insurance Co DFE: Pooled Separate Account $8,944
Alliancebernstein Global Thematic G Lincoln National Life Insurance Co DFE: Pooled Separate Account $8,752
Lvip Global Moderate Allocation Mgd Lincoln National Life Insurance Co DFE: Pooled Separate Account $7,502
Fidelity Vip Contrafund Lincoln National Life Insurance Co DFE: Pooled Separate Account $7,288
Delaware Vip Small Cap Growth Lincoln National Life Insurance Co DFE: Pooled Separate Account $7,159
Lvip Ssga S & P 500 Index Lincoln National Life Insurance Co DFE: Pooled Separate Account $6,577
American Funds International Lincoln National Life Insurance Co DFE: Pooled Separate Account $6,510
Lvip Delaware Bond Lincoln National Life Insurance Co DFE: Pooled Separate Account $6,321
Delaware Vip Smid Cap Growth Lincoln National Life Insurance Co DFE: Pooled Separate Account $5,658
Delaware Vip High Yield Lincoln National Life Insurance Co DFE: Pooled Separate Account $5,068
Lvip Baron Growth Opportunities Lincoln National Life Insurance Co DFE: Pooled Separate Account $4,557
Lvip Dimensional U.S. Core Equity 1 Lincoln National Life Insurance Co DFE: Pooled Separate Account $4,518
Lvip Mondrian International Value Lincoln National Life Insurance Co DFE: Pooled Separate Account $4,044
Delaware Vip Reit Lincoln National Life Insurance Co DFE: Pooled Separate Account $3,649
Lvip Delaware Special Opportunities Lincoln National Life Insurance Co DFE: Pooled Separate Account $3,394
Fidelity Vip Growth Lincoln National Life Insurance Co DFE: Pooled Separate Account $2,976
Lvip Vanguard Domestic Equity Lincoln National Life Insurance Co DFE: Pooled Separate Account $2,550
Lvip Global Conservative Allocation Lincoln National Life Insurance Co DFE: Pooled Separate Account $2,422
Lvip Blackrock Equity Dividend Rpm Lincoln National Life Insurance Co DFE: Pooled Separate Account $2,245
Lvip Delaware Social Awareness Lincoln National Life Insurance Co DFE: Pooled Separate Account $2,076
American Funds Global Growth Lincoln National Life Insurance Co DFE: Pooled Separate Account $1,680
Lvip Ssga Small - Cap Index Lincoln National Life Insurance Co DFE: Pooled Separate Account $1,508
Delaware Vip Value Lincoln National Life Insurance Co DFE: Pooled Separate Account $853
Lvip Global Growth Allocation Mangd Lincoln National Life Insurance Co DFE: Pooled Separate Account $685
Total $318,978

Insurance Information

Insurance Information

Insurance Carrier Summary Persons Covered
Principal Life Insurance Company 162
EIN 42-0127290
Industry Code 61271
Contract Number 613953
Contract Year 04/01/2017 — 12/31/2017
Value in General Account at Year End $0
Value in Separate Accounts at Year End $0
Insurance Fees and Commissions $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 CUSTODIAL GUARANTEED INTEREST CONTRACT
Balance at the end of the previous year $0
Additions $197,124
Contributions Deposited during the year $18,236
Dividends and credits $0
Interest credited during the year $868
Transferred from separate account $0
Other $178,020
Total of Balance and Additions $197,124
Deductions $116,738
Disbursed from fund to pay benefits or purchase annuities during the year $0
Administration charge made by carrier $16
Transferred to Separate Account $0
Other $116,722
Balance at the end of the current year $80,386
The Lincoln National Life Insurance Company 26
EIN 35-0472300
Industry Code 65676
Contract Number CR27210
Contract Year 01/01/2017 — 12/31/2017
Value in General Account at Year End $29,831
Value in Separate Accounts at Year End $0
Insurance Fees and Commissions $680
Persons Receiving Commissions and Fees
Agent/Broker Organization Code Commissions Paid Fees Paid Purpose of Fees Paid
Lincoln Financial Advisors 1300 S Clinton St. Suite 150 Fort Wayne, IN 46802 -9999 Agent or Broker other than Insurance $680 $0 SALES AND BASE COMMISSIONS
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 VARIABLE ANNUITY
Balance at the end of the previous year $36,721
Additions $1,066
Contributions Deposited during the year $0
Dividends and credits $0
Interest credited during the year $1,066
Transferred from separate account $0
Other $0
Total of Balance and Additions $37,787
Deductions $7,956
Disbursed from fund to pay benefits or purchase annuities during the year $0
Administration charge made by carrier $155
Transferred to Separate Account $7,801
Other $0
Balance at the end of the current year $29,831
The Lincoln National Life Insurance Company 16
EIN 35-0472300
Industry Code 65676
Contract Number CR28348
Contract Year 01/01/2017 — 12/31/2017
Value in General Account at Year End $22,954
Value in Separate Accounts at Year End $0
Insurance Fees and Commissions $201
Persons Receiving Commissions and Fees
Agent/Broker Organization Code Commissions Paid Fees Paid Purpose of Fees Paid
Lincoln Financial Advisors 1300 S Clinton St Ste #150 Fort Wayne, IN 46802 -9999 Agent or Broker other than Insurance $201 $0 SALES AND BASE COMMISSIONS
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 VARIABLE ANNUITY
Balance at the end of the previous year $22,180
Additions $774
Contributions Deposited during the year $0
Dividends and credits $0
Interest credited during the year $774
Transferred from separate account $0
Other $0
Total of Balance and Additions $22,954
Deductions $0
Disbursed from fund to pay benefits or purchase annuities during the year $0
Administration charge made by carrier $0
Transferred to Separate Account $0
Other $0
Balance at the end of the current year $22,954
The Lincoln National Life Insurance Company 1
EIN 35-0472300
Industry Code 65676
Contract Number EX28348
Contract Year 01/01/2017 — 12/31/2017
Value in General Account at Year End $2,928
Value in Separate Accounts at Year End $0
Insurance Fees and Commissions $29
Persons Receiving Commissions and Fees
Agent/Broker Organization Code Commissions Paid Fees Paid Purpose of Fees Paid
Lincoln Financial Advisors 1300 S Clinton St Ste #150 Fort Wayne, IN 46802 -9999 Agent or Broker other than Insurance $29 $0 SALES AND BASE COMMISSIONS
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 VARIABLE ANNUITY
Balance at the end of the previous year $2,830
Additions $98
Contributions Deposited during the year $0
Dividends and credits $0
Interest credited during the year $98
Transferred from separate account $0
Other $0
Total of Balance and Additions $2,928
Deductions $0
Disbursed from fund to pay benefits or purchase annuities during the year $0
Administration charge made by carrier $0
Transferred to Separate Account $0
Other $0
Balance at the end of the current year $2,928
The Lincoln National Life Insurance Company 1
EIN 35-0472300
Industry Code 65676
Contract Number EX27210
Contract Year 01/01/2017 — 12/31/2017
Value in General Account at Year End $23,542
Value in Separate Accounts at Year End $0
Insurance Fees and Commissions $82
Persons Receiving Commissions and Fees
Agent/Broker Organization Code Commissions Paid Fees Paid Purpose of Fees Paid
Lincoln Financial Advisors 1300 S Clinton St Ste #150 Fort Wayne, IN 46802 -9999 Agent or Broker other than Insurance $82 $0 SALES AND BASE COMMISSIONS
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 VARIABLE ANNUITY
Balance at the end of the previous year $22,739
Additions $828
Contributions Deposited during the year $0
Dividends and credits $0
Interest credited during the year $828
Transferred from separate account $0
Other $0
Total of Balance and Additions $23,567
Deductions $25
Disbursed from fund to pay benefits or purchase annuities during the year $0
Administration charge made by carrier $25
Transferred to Separate Account $0
Other $0
Balance at the end of the current year $23,542