AVON VILLAGE FAMILY DENTISTRY PC

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1996-01-01
Business code	621210
Sponsor’s telephone number	8606781140
Plan sponsor’s address	32 EAST MAIN STREET, AVON, CT, 060013801

Signature of

Role	Plan administrator
Date	2024-06-12
Name of individual signing	LAUREN MENTASTI
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1996-01-01
Business code	621210
Sponsor’s telephone number	8606781140
Plan sponsor’s address	32 EAST MAIN STREET, AVON, CT, 060013801

Signature of

Role	Plan administrator
Date	2023-03-14
Name of individual signing	LAUREN MENTASTI
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1996-01-01
Business code	621210
Sponsor’s telephone number	8606781140
Plan sponsor’s address	32 EAST MAIN STREET, AVON, CT, 060013801

Signature of

Role	Plan administrator
Date	2022-04-01
Name of individual signing	LAUREN MENTASTI
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1996-01-01
Business code	621210
Sponsor’s telephone number	8606781140
Plan sponsor’s address	32 EAST MAIN STREET, AVON, CT, 060013801

Signature of

Role	Plan administrator
Date	2021-02-09
Name of individual signing	LAUREN MENTASTI
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1996-01-01
Business code	621210
Sponsor’s telephone number	8606781140
Plan sponsor’s address	32 EAST MAIN STREET, AVON, CT, 060013801

Signature of

Role	Plan administrator
Date	2020-02-06
Name of individual signing	LAUREN MENTASTI
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1996-01-01
Business code	621210
Sponsor’s telephone number	8606781140
Plan sponsor’s address	32 EAST MAIN STREET, AVON, CT, 060013801

Signature of

Role	Plan administrator
Date	2019-04-09
Name of individual signing	LAUREN MENTASTI
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1996-01-01
Business code	621210
Sponsor’s telephone number	8606781140
Plan sponsor’s address	32 EAST MAIN STREET, AVON, CT, 060013801

Signature of

Role	Plan administrator
Date	2018-03-06
Name of individual signing	LAUREN MENTASTI
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1996-01-01
Business code	621210
Sponsor’s telephone number	8606781140
Plan sponsor’s address	32 EAST MAIN STREET, AVON, CT, 060013801

Signature of

Role	Plan administrator
Date	2017-03-08
Name of individual signing	LAUREN MENTASTI
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1996-01-01
Business code	621210
Sponsor’s telephone number	8606781140
Plan sponsor’s address	32 EAST MAIN STREET, AVON, CT, 060013801

Signature of

Role	Plan administrator
Date	2016-06-27
Name of individual signing	LAUREN MENTASTI
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2016-06-27
Name of individual signing	LAUREN MENTASTI
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1996-01-01
Business code	621210
Sponsor’s telephone number	8606781140
Plan sponsor’s address	32 EAST MAIN STREET, AVON, CT, 060013801

Signature of

Role	Plan administrator
Date	2015-05-26
Name of individual signing	ANN M. SAGALYN, D.M.D.
Valid signature	Filed with authorized/valid electronic signature