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FORM 5500 DATA

Intercare Community Health Network 401k Retirement Plan

Overview

Plan Information

  • Plan Year04/01/2012 — 03/31/2013
  • Date of Plan06/01/2004
  • Net Assets as of 03/31/2013 $4,753,034
  • 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 03/31/2013

  • Active (Eligible) Participants384
  • Retired or separated participants receiving benefits0
  • Other retired or separated participants entitled to future benefits17
  • Subtotal401
  • Deceased participants whose beneficiaries are receiving or are entitled to receive benefits0
  • Total401
  • Total number of participants as of 04/01/2012552
  • Number of participants with account balances227
  • Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested11

Expenses

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

Sponsor Information

  • Address50 Industrial Park Rd
  • CityBangor
  • StateMI
  • Zip49013-1246
  • Telephone(269) 427-7937
  • EIN38-2009364
  • Industry Code621498
  • Named AdministratorPatrick Sullivan
  • Named Plan SponsorPatrick Sullivan

Audit Information

  • Audit StatusAudited
  • AuditorYeo & Yeo, Pc
  • Auditor EIN38-2706146
  • Audit Opinion Disclaimer
  • Audit TypeLimited Scope Audit

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.
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? 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 $1,070,770
Contributions $651,178
Cash Contributions $651,178
Cash from Employers $0
Cash from Participants $642,896
Others (including rollovers) $8,282
Noncash Contributions $0
Total Earnings on Investments $419,647
Total Interest $2,809
Interest-Bearing Cash $0
U.S. Government Securities $0
Corporate Debt Instruments $0
Loans (other than to participants) $0
Participant Loans $2,625
Interest from Other Investments $184
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 $416,838
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 $0
Other Income $-55
Expenses $716,443
Total Benefit Payments $708,088
Directly to participants or beneficiaries, including direct rollovers $708,088
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 $8,355
Professional Fees $0
Contract Administrator Fees $8,355
Investment Advisory and management fees $0
Other Administrative Fees $0
Net Income $354,327
Transfers of Assets to this Plan $0
Transfers of Assets from this Plan $0

Asset and Liability Statement

03/31/2013 03/31/2012 Change YOY
Total Assets $4,753,034 $4,398,707 8.06%
Total noninterest-bearing cash $0 $0 0.0%
Receivables $0 $22,831 -100.00%
Employer Contributions $0 $0 0.0%
Participant Contributions $0 $22,831 -100.00%
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 $87,277 $70,458 23.87%
Value of interest in common/collective trusts $0 $0 0.0%
Value of interest in pooled separate accounts $4,615,499 $4,246,139 8.70%
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 $0 $0 0.0%
Value of funds held in insurance co. general account $50,258 $59,279 -15.22%
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 $4,753,034 $4,398,707 8.06%

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
Principal Life Insurance Company Contract Administrator, Participant loan processing, Direct payment from the plan, Recordkeeping fees Contract Administrator $8,354 $0 $8,354
Total $8,354 $0 $8,354

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
Prin Lifetime 2020 Sep Acct-R1 Principal Life Insurance Company DFE: Pooled Separate Account $765,269
Prin Lifetime 2030 Sep Acct-R1 Principal Life Insurance Company DFE: Pooled Separate Account $470,656
Prin Diversified Intl Sa-R1 Principal Life Insurance Company DFE: Pooled Separate Account $346,058
Prin Largecap Value I Sa-R1 Principal Life Insurance Company DFE: Pooled Separate Account $309,006
Prin Lifetime 2040 Sep Acct-R1 Principal Life Insurance Company DFE: Pooled Separate Account $295,209
Prin Lifetime 2050 Sep Acct-R1 Principal Life Insurance Company DFE: Pooled Separate Account $264,226
Prin Bond and Mortgage Sa-R1 Principal Life Insurance Company DFE: Pooled Separate Account $260,088
Prin U.S. Property Sep Acct-R1 Principal Life Insurance Company DFE: Pooled Separate Account $248,714
Prin Midcap Value I Sa-R1 Principal Life Insurance Company DFE: Pooled Separate Account $213,661
Prin Lgcap S&P 500 Index Sa-R1 Principal Life Insurance Company DFE: Pooled Separate Account $208,334
Prin Smcap S&P 600 Index Sa-R1 Principal Life Insurance Company DFE: Pooled Separate Account $176,373
Prin Midcap Growth III Sa-R1 Principal Life Insurance Company DFE: Pooled Separate Account $173,477
Prin Smallcap Value II Sa-R1 Principal Life Insurance Company DFE: Pooled Separate Account $157,341
Prin Money Market Sep Acct-R1 Principal Life Insurance Company DFE: Pooled Separate Account $136,153
Prin Largecap Growth II Sa-R1 Principal Life Insurance Company DFE: Pooled Separate Account $121,282
Prin Largecap Value III Sa-R1 Principal Life Insurance Company DFE: Pooled Separate Account $98,348
Prin Smallcap Growth II Sa-R1 Principal Life Insurance Company DFE: Pooled Separate Account $88,687
Prin Lifetime 2010 Sep Acct-R1 Principal Life Insurance Company DFE: Pooled Separate Account $71,150
Prin Lifetime 2015 Sep Acct-R1 Principal Life Insurance Company DFE: Pooled Separate Account $69,581
Prin Lifetime 2025 Sep Acct-R1 Principal Life Insurance Company DFE: Pooled Separate Account $48,248
Prin Lifetime 2055 Sep Acct-R1 Principal Life Insurance Company DFE: Pooled Separate Account $39,377
Prin Lifetime 2035 Sep Acct-R1 Principal Life Insurance Company DFE: Pooled Separate Account $24,405
Prin Lifetime 2045 Sep Acct-R1 Principal Life Insurance Company DFE: Pooled Separate Account $23,934
Prin Lifetime Strat Inc Sa-R1 Principal Life Insurance Company DFE: Pooled Separate Account $5,924
Total $4,615,501

Insurance Information

Insurance Information

Insurance Carrier Summary Persons Covered
Principal Life Insurance Company 401
EIN 42-0127290
Industry Code 61271
Contract Number 709875
Contract Year 04/01/2012 — 03/31/2013
Value in General Account at Year End $50,258
Value in Separate Accounts at Year End $4,615,499
Insurance Fees and Commissions $7,800
Persons Receiving Commissions and Fees
Agent/Broker Organization Code Commissions Paid Fees Paid Purpose of Fees Paid
Doherty, Scott M. 450 West Centre Ave Portage, MI 49024 Insurance Agent or Broker $7,800 $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 FLEXIBLE INVESTMENT ANNUITY
Balance at the end of the previous year $59,529
Additions $8,969
Contributions Deposited during the year $7,679
Dividends and credits $0
Interest credited during the year $184
Transferred from separate account $0
Other $1,106
Total of Balance and Additions $68,498
Deductions $17,934
Disbursed from fund to pay benefits or purchase annuities during the year $17,572
Administration charge made by carrier $132
Transferred to Separate Account $0
Other $230
Balance at the end of the current year $50,564