DRS. COUTANT, SEDERQUIST, NEBOR & CLAUSS, DENTISTS, P.C.

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1985-09-09
Business code	621210
Sponsor’s telephone number	8604828588
Plan sponsor’s address	55 PECK RD, TORRINGTON, CT, 067906106

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1985-09-09
Business code	621210
Sponsor’s telephone number	8604828588
Plan sponsor’s address	55 PECK RD, TORRINGTON, CT, 067906106

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1985-09-09
Business code	621210
Sponsor’s telephone number	8604828588
Plan sponsor’s address	55 PECK RD, TORRINGTON, CT, 067906106

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1985-09-09
Business code	621210
Sponsor’s telephone number	8604828588
Plan sponsor’s address	55 PECK RD, TORRINGTON, CT, 067906106

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1985-09-09
Business code	621210
Sponsor’s telephone number	8604828588
Plan sponsor’s address	55 PECK RD, TORRINGTON, CT, 067906106

Signature of

Role	Plan administrator
Date	2014-05-05
Name of individual signing	ROBERT C. SEDERQUIST
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2014-05-05
Name of individual signing	ROBERT C. SEDERQUIST
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1985-09-09
Business code	621210
Sponsor’s telephone number	8604828588
Plan sponsor’s address	55 PECK RD, TORRINGTON, CT, 067906106

Plan administrator’s name and address

Administrator’s EIN	060888311
Plan administrator’s name	DRS. COUTANT, SEDERQUIST, NEBOR & CLAUSS DENTISTS, P.C.
Plan administrator’s address	55 PECK RD, TORRINGTON, CT, 067906106
Administrator’s telephone number	8604828588

Signature of

Role	Plan administrator
Date	2012-11-07
Name of individual signing	ROBERT C. SEDERQUIST
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2012-11-07
Name of individual signing	ROBERT C. SEDERQUIST
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1985-09-09
Business code	621210
Sponsor’s telephone number	8604828588
Plan sponsor’s address	55 PECK RD, TORRINGTON, CT, 067906106

Plan administrator’s name and address

Administrator’s EIN	060888311
Plan administrator’s name	DRS. COUTANT, SEDERQUIST, NEBOR & CLAUSS DENTISTS, P.C.
Plan administrator’s address	55 PECK RD, TORRINGTON, CT, 067906106
Administrator’s telephone number	8604828588

Signature of

Role	Plan administrator
Date	2012-04-18
Name of individual signing	KELLY CLAUSS
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2012-04-18
Name of individual signing	KELLY CLAUSS
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1985-09-09
Business code	621210
Sponsor’s telephone number	8604828588
Plan sponsor’s address	55 PECK RD, TORRINGTON, CT, 067906106

Plan administrator’s name and address

Administrator’s EIN	060888311
Plan administrator’s name	DRS. COUTANT, SEDERQUIST, NEBOR & CLAUSS DENTISTS, P.C.
Plan administrator’s address	55 PECK RD, TORRINGTON, CT, 067906106
Administrator’s telephone number	8604828588

Signature of

Role	Plan administrator
Date	2011-05-24
Name of individual signing	KELLY CLAUSS
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2011-05-24
Name of individual signing	KELLY CLAUSS
Valid signature	Filed with authorized/valid electronic signature