HOSSEIN HEDAYATI, M.D., P.C.

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Three-digit plan number (PN)	001
Effective date of plan	1977-07-05
Business code	621111
Sponsor’s telephone number	7189796167
Plan sponsor’s mailing address	36 COPPERFLAGG LANE, STATEN ISLAND, NY, 10304
Plan sponsor’s address	36 COPPERFLAGG LANE, STATEN ISLAND, NY, 10304

Plan administrator’s name and address

Administrator’s EIN	112430052
Plan administrator’s name	HOSSEIN HEDAYATI, M.D., P.C.
Plan administrator’s address	36 COPPERFLAGG LANE, STATEN ISLAND, NY, 10304
Administrator’s telephone number	7189796167

Number of participants as of the end of the plan year

Active participants	1
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	1
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	2010-11-18
Name of individual signing	HOSSEIN HEDAYATI
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2010-11-18
Name of individual signing	HOSSEIN HEDAYATI
Valid signature	Filed with authorized/valid electronic signature