ALLIANCE FOUNDATION OF FLORIDA, INC.

Contacts

Phone	+1 386-257-4400
Fax	3862574372

Authorized person

Name	MR. RANDOLPH LEE KERNON II
Role	EXECUTIVE DIRECTOR
Phone	3865474686

Taxonomy

Taxonomy Code	310400000X - Assisted Living Facility
License Number	AL5400
State	FL
Is Primary	Yes

Other Provider Identifiers

Issuer	STATE OF FLORIDA AHCA
Number	AL5400
State	FL

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2012-01-01
Business code	623000
Sponsor’s telephone number	3862383333
Plan sponsor’s address	570 NATIONAL HEALTH CARE DR, DAYTONA BEACH, FL, 32114

Signature of

Role	Plan administrator
Date	2023-05-26
Name of individual signing	LAURA STONE
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2012-01-01
Business code	623000
Sponsor’s telephone number	3862574400
Plan sponsor’s address	570 NATIONAL HEALTHCARE DR, DAYTONA BEACH, FL, 32114

Signature of

Role	Plan administrator
Date	2022-05-25
Name of individual signing	LAURA STONE
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2012-01-01
Business code	623000
Sponsor’s telephone number	3862574400
Plan sponsor’s address	595 N WILLIAMSON BLVD, DAYTONA BEACH, FL, 32114

Signature of

Role	Plan administrator
Date	2021-08-02
Name of individual signing	LAURA STONE
Valid signature	Filed with authorized/valid electronic signature

Three-digit plan number (PN)	001
Effective date of plan	2012-01-01
Business code	623000
Sponsor’s telephone number	3862574400
Plan sponsor’s address	595 N WILLIAMSON BLVD, DAYTONA BEACH, FL, 32114

Signature of

Role	Plan administrator
Date	2020-06-23
Name of individual signing	LSTONE0528
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2012-01-01
Business code	623000
Sponsor’s telephone number	3862574400
Plan sponsor’s address	595 N WILLIAMSON BLVD, DAYTONA BEACH, FL, 32114

Signature of

Role	Plan administrator
Date	2020-06-30
Name of individual signing	LAURA STONE
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2012-01-01
Business code	623000
Sponsor’s telephone number	3862574400
Plan sponsor’s address	595 N WILLIAMSON BLVD, DAYTONA BEACH, FL, 32114

Signature of

Role	Plan administrator
Date	2019-05-30
Name of individual signing	LAURA STONE
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2012-01-01
Business code	623000
Sponsor’s telephone number	3862574400
Plan sponsor’s address	595 N WILLIAMSON BLVD, DAYTONA BEACH, FL, 32114

Signature of

Role	Plan administrator
Date	2018-05-17
Name of individual signing	LAURA STONE
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2012-01-01
Business code	623000
Sponsor’s telephone number	3862574400
Plan sponsor’s address	595 N WILLIAMSON BLVD, DAYTONA BEACH, FL, 32114

Signature of

Role	Plan administrator
Date	2017-05-18
Name of individual signing	LAURA STONE
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2012-01-01
Business code	623000
Sponsor’s telephone number	3862574400
Plan sponsor’s address	595 N WILLIAMSON BLVD, DAYTONA BEACH, FL, 32114

Signature of

Role	Plan administrator
Date	2016-05-31
Name of individual signing	NANCY BARKER
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2012-01-01
Business code	623000
Sponsor’s telephone number	3862574400
Plan sponsor’s address	595 N WILLIAMSON BLVD, DAYTONA BEACH, FL, 32114

Signature of

Role	Plan administrator
Date	2015-07-01
Name of individual signing	NANCY BARKER
Valid signature	Filed with authorized/valid electronic signature