RALPH DEFELICE, D. D. S., P.C.

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	1976-08-01
Business code	621210
Sponsor’s telephone number	3157893067
Plan sponsor’s address	404 WILLIAM STREET, GENEVA, NY, 14456

Signature of

Role	Plan administrator
Date	2013-04-13
Name of individual signing	RALPH DEFELICE
Role	Employer/plan sponsor
Date	2013-04-13
Name of individual signing	RALPH DEFELICE

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	1976-08-01
Business code	621210
Sponsor’s telephone number	3157893067
Plan sponsor’s address	404 WILLIAM STREET, GENEVA, NY, 14456

Plan administrator’s name and address

Administrator’s EIN	161012501
Plan administrator’s name	RALPH DEFELICE D.D.S., P. C.
Plan administrator’s address	404 WILLIAM STREET, GENEVA, NY, 14456
Administrator’s telephone number	3157893067

Signature of

Role	Plan administrator
Date	2012-06-05
Name of individual signing	RALPH DEFELICE
Role	Employer/plan sponsor
Date	2012-06-05
Name of individual signing	RALPH DEFELICE

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	1976-08-01
Business code	621210
Sponsor’s telephone number	3157893067
Plan sponsor’s mailing address	404 WILLIAM STREET, GENEVA, NY, 14456
Plan sponsor’s address	404 WILLIAM STREET, GENEVA, NY, 14456

Plan administrator’s name and address

Administrator’s EIN	161012501
Plan administrator’s name	RALPH DEFELICE D.D.S., P. C.
Plan administrator’s address	404 WILLIAM STREET, GENEVA, NY, 14456
Administrator’s telephone number	3157893067

Number of participants as of the end of the plan year

Active participants	3
Retired or separated participants receiving benefits	0
Other retired or separated participants entitled to future benefits	0
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits	0
Number of participants with account balances as of the end of the plan year	3
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	0

Signature of

Role	Plan administrator
Date	2011-07-12
Name of individual signing	RALPH DEFELICE
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2011-07-12
Name of individual signing	RALPH DEFELICE
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	1976-08-01
Business code	621210
Sponsor’s telephone number	3157893067
Plan sponsor’s mailing address	404 WILLIAM STREET, GENEVA, NY, 14456
Plan sponsor’s address	404 WILLIAM STREET, GENEVA, NY, 14456

Plan administrator’s name and address

Administrator’s EIN	161012501
Plan administrator’s name	RALPH DEFELICE D.D.S., P. C.
Plan administrator’s address	404 WILLIAM STREET, GENEVA, NY, 14456
Administrator’s telephone number	3157893067

Number of participants as of the end of the plan year

Active participants	4
Retired or separated participants receiving benefits	0
Other retired or separated participants entitled to future benefits	0
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits	0
Number of participants with account balances as of the end of the plan year	4
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	0

Signature of

Role	Plan administrator
Date	2010-07-08
Name of individual signing	RALPH DEFELICE
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2010-07-08
Name of individual signing	RALPH DEFELICE
Valid signature	Filed with authorized/valid electronic signature