BARIATRIC SURGICAL ASSOCIATES, LLC

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1995-01-01
Business code	621111
Sponsor’s telephone number	6077965936
Plan sponsor’s mailing address	100 JOHN ROEMMELT DR STE 202, HORSEHEADS, NY, 148458303
Plan sponsor’s address	100 JOHN ROEMMELT DR STE 202, HORSEHEADS, NY, 148458303

Plan administrator’s name and address

Administrator’s EIN	141858346
Plan administrator’s name	BARIATRIC SURGICAL ASSOCIATES, LLC
Plan administrator’s address	100 JOHN ROEMMELT DR STE 202, HORSEHEADS, NY, 148458303
Administrator’s telephone number	6077965936

Number of participants as of the end of the plan year

Active participants	0
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	0
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	2010-08-08
Name of individual signing	ROBERT COLE
Valid signature	Filed with authorized/valid electronic signature