CITRUS ORAL & FACIAL SURGERY, P.A.

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1990-01-01
Business code	621210
Sponsor’s telephone number	3527954994
Plan sponsor’s address	6129 WEST CORPORATE OAKS DRIVE, CRYSTAL RIVER, FL, 34429

Signature of

Role	Plan administrator
Date	2023-12-19
Name of individual signing	RUSHI S PATEL
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1990-01-01
Business code	621210
Sponsor’s telephone number	3527954994
Plan sponsor’s address	6129 WEST CORPORATE OAKS DRIVE, CRYSTAL RIVER, FL, 34429

Signature of

Role	Plan administrator
Date	2022-07-27
Name of individual signing	RUSHI S PATEL
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1990-01-01
Business code	621210
Sponsor’s telephone number	3527954994
Plan sponsor’s address	6129 WEST CORPORATE OAKS DRIVE, CRYSTAL RIVER, FL, 34429

Signature of

Role	Plan administrator
Date	2021-10-12
Name of individual signing	ROBERT L. BROCKETT, JR., DMD
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1990-01-01
Business code	621210
Sponsor’s telephone number	3527954994
Plan sponsor’s address	6129 WEST CORPORATE OAKS DRIVE, CRYSTAL RIVER, FL, 34429

Signature of

Role	Plan administrator
Date	2020-10-13
Name of individual signing	ROBERT L. BROCKETT, JR., DMD
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1990-01-01
Business code	621210
Sponsor’s telephone number	3527954994
Plan sponsor’s address	6129 WEST CORPORATE OAKS DRIVE, CRYSTAL RIVER, FL, 34429

Signature of

Role	Plan administrator
Date	2019-09-06
Name of individual signing	ROBERT L. BROCKETT, JR., DMD
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1990-01-01
Business code	621210
Sponsor’s telephone number	3527954994
Plan sponsor’s address	6129 WEST CORPORATE OAKS DRIVE, CRYSTAL RIVER, FL, 34429

Plan administrator’s name and address

Administrator’s EIN	205898651
Plan administrator’s name	CITRUS ORAL & FACIAL SURGERY, P.A.
Plan administrator’s address	6129 WEST CORPORATE OAKS DRIVE, CRYSTAL RIVER, FL, 34429
Administrator’s telephone number	3527954994

Signature of

Role	Plan administrator
Date	2018-07-16
Name of individual signing	ROBERT L. BROCKETT, JR., DMD
Valid signature	Filed with authorized/valid electronic signature