BUCKLEY ROAD PEDIATRICS, PLLC

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2016-10-01
Business code	621111
Sponsor’s telephone number	3154586601
Plan sponsor’s address	5116 W. TAFT ROAD, LIVERPOOL, NY, 13088

Signature of

Role	Plan administrator
Date	2024-07-18
Name of individual signing	JENNIFER SACKS, MD

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2016-10-01
Business code	621111
Sponsor’s telephone number	3154586601
Plan sponsor’s address	5116 W. TAFT ROAD, LIVERPOOL, NY, 13088

Signature of

Role	Plan administrator
Date	2023-07-10
Name of individual signing	JENNIFER SACKS, MD

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2016-10-01
Business code	621111
Sponsor’s telephone number	3154586601
Plan sponsor’s address	5116 W. TAFT ROAD, LIVERPOOL, NY, 13088

Signature of

Role	Plan administrator
Date	2022-04-28
Name of individual signing	JENNIFER SACKS, MD

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2016-10-01
Business code	621111
Sponsor’s telephone number	3154586601
Plan sponsor’s address	5116 W. TAFT ROAD, LIVERPOOL, NY, 13088

Signature of

Role	Plan administrator
Date	2021-08-03
Name of individual signing	JENNIFER SACKS, MD
Role	Employer/plan sponsor
Date	2021-08-03
Name of individual signing	JONI STOUDT

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2016-10-01
Business code	621111
Sponsor’s telephone number	3154586601
Plan sponsor’s address	5116 W. TAFT ROAD, LIVERPOOL, NY, 13088

Signature of

Role	Plan administrator
Date	2020-06-08
Name of individual signing	JENNIFER SACKS, MD

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2016-10-01
Business code	621111
Sponsor’s telephone number	3154586601
Plan sponsor’s address	7270 BUCKLEY ROAD, NORTH SYRACUSE, NY, 13212

Signature of

Role	Plan administrator
Date	2019-07-12
Name of individual signing	JENNIFER SACKS, MD

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2016-10-01
Business code	621111
Sponsor’s telephone number	3154586601
Plan sponsor’s address	7270 BUCKLEY ROAD, NORTH SYRACUSE, NY, 13212

Signature of

Role	Plan administrator
Date	2018-06-27
Name of individual signing	JENNIFER SACKS, MD

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2016-10-01
Business code	621111
Sponsor’s telephone number	3154586601
Plan sponsor’s address	7270 BUCKLEY ROAD, NORTH SYRACUSE, NY, 13212

Signature of

Role	Plan administrator
Date	2017-05-24
Name of individual signing	JENNIFER SACKS, MD