MICHAEL S. BUCHHOLTZ, M.D., P.C.

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2001-09-01
Business code	621111
Sponsor’s telephone number	6314276060
Plan sponsor’s address	270 PULASKI RD, GREENLAWN, NY, 11740

Signature of

Role	Plan administrator
Date	2015-05-01
Name of individual signing	MICHAEL BUCHHOLTZ
Role	Employer/plan sponsor
Date	2015-05-01
Name of individual signing	MICHAEL BUCHHOLTZ

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2001-09-01
Business code	621111
Sponsor’s telephone number	6314276060
Plan sponsor’s address	270 PULASKI RD, GREENLAWN, NY, 11740

Signature of

Role	Plan administrator
Date	2013-07-30
Name of individual signing	MICHAEL BUCHHOLTZ
Role	Employer/plan sponsor
Date	2013-07-30
Name of individual signing	MICHAEL BUCHHOLTZ

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2001-09-01
Business code	621111
Sponsor’s telephone number	6314276060
Plan sponsor’s address	270 PULASKI RD, GREENLAWN, NY, 11740

Plan administrator’s name and address

Administrator’s EIN	113625064
Plan administrator’s name	MICHAEL S. BUCHHOLTZ, M.D., P.C.
Plan administrator’s address	270 PULASKI RD, GREENLAWN, NY, 11740
Administrator’s telephone number	6314276060

Signature of

Role	Plan administrator
Date	2012-09-10
Name of individual signing	MICHAEL BUCHHOLTZ
Role	Employer/plan sponsor
Date	2012-09-10
Name of individual signing	MICHAEL BUCHHOLTZ

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2001-09-01
Business code	621111
Sponsor’s telephone number	6314276060
Plan sponsor’s mailing address	270 PULASKI RD STE D, GREENLAWN, NY, 117401605
Plan sponsor’s address	270 PULASKI RD STE D, GREENLAWN, NY, 117401605

Plan administrator’s name and address

Administrator’s EIN	113625064
Plan administrator’s name	MICHAEL S. BUCHHOLTZ, M.D., P.C.
Plan administrator’s address	270 PULASKI RD STE D, GREENLAWN, NY, 117401605
Administrator’s telephone number	6314276060

Number of participants as of the end of the plan year

Active participants	11
Retired or separated participants receiving benefits	0
Other retired or separated participants entitled to future benefits	1
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	12
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	1

Signature of

Role	Plan administrator
Date	2011-09-07
Name of individual signing	MICHAEL BUCHHOLTZ
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2001-09-01
Business code	621111
Sponsor’s telephone number	6314276060
Plan sponsor’s mailing address	270 PULASKI RD STE D, GREENLAWN, NY, 11740
Plan sponsor’s address	270 PULASKI RD STE D, GREENLAWN, NY, 11740

Plan administrator’s name and address

Administrator’s EIN	113625064
Plan administrator’s name	MICHAEL S. BUCHHOLTZ, M.D., P.C.
Plan administrator’s address	270 PULASKI RD STE D, GREENLAWN, NY, 11740
Administrator’s telephone number	6314276060

Number of participants as of the end of the plan year

Active participants	12
Retired or separated participants receiving benefits	0
Other retired or separated participants entitled to future benefits	2
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	14
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	1

Signature of

Role	Plan administrator
Date	2010-09-13
Name of individual signing	MICHAEL BUCHHOLTZ
Valid signature	Filed with authorized/valid electronic signature