DONALD T. EVANS, M.D., P.C.

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1976-06-01
Business code	621111
Sponsor’s telephone number	2034265626
Plan sponsor’s address	P.O. BOX 652, SANDY HOOK, CT, 06482

Plan administrator’s name and address

Administrator’s EIN	060864265
Plan administrator’s name	DONALD T. EVANS, M.D., P.C.
Plan administrator’s address	P.O. BOX 652, SANDY HOOK, CT, 06482
Administrator’s telephone number	2034265626

Signature of

Role	Plan administrator
Date	2011-03-15
Name of individual signing	DONALD T. EVANS, M.D.
Valid signature	Filed with authorized/valid electronic signature