JOHN L. CEPLENSKI, JR., D.D.S., P.C.

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1978-05-01
Business code	621210
Sponsor’s telephone number	8606213032
Plan sponsor’s address	25 MOORELAND DRIVE, SOUTHINGTON, CT, 06489

Plan administrator’s name and address

Administrator’s EIN	060978899
Plan administrator’s name	JOHN L. CEPLENSKI, JR., D.D.S., P.C.
Plan administrator’s address	25 MOORELAND DRIVE, SOUTHINGTON, CT, 06489
Administrator’s telephone number	8606213032

Signature of

Role	Plan administrator
Date	2012-04-26
Name of individual signing	JOHN L. CEPLENSKI
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1978-05-01
Business code	621210
Sponsor’s telephone number	8606213032
Plan sponsor’s address	25 MOORELAND DRIVE, SOUTHINGTON, CT, 06489

Plan administrator’s name and address

Administrator’s EIN	060978899
Plan administrator’s name	JOHN L. CEPLENSKI, JR., D.D.S., P.C.
Plan administrator’s address	25 MOORELAND DRIVE, SOUTHINGTON, CT, 06489
Administrator’s telephone number	8606213032

Signature of

Role	Plan administrator
Date	2011-06-27
Name of individual signing	JOHN L. CEPLENSKI
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1978-05-01
Business code	621210
Sponsor’s telephone number	8606285531
Plan sponsor’s address	27 MERIDEN AVENUE, SOUTHINGTON, CT, 06489

Plan administrator’s name and address

Administrator’s EIN	060978899
Plan administrator’s name	JOHN L. CEPLENSKI, JR., D.D.S., P.C.
Plan administrator’s address	27 MERIDEN AVENUE, SOUTHINGTON, CT, 06489
Administrator’s telephone number	8606285531

Signature of

Role	Plan administrator
Date	2010-12-08
Name of individual signing	JOHN L. CEPLENSKI
Valid signature	Filed with authorized/valid electronic signature