SAMUEL O. DORN, D.D.S., P.A.

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1986-01-01
Business code	621210
Sponsor’s telephone number	9549666400
Plan sponsor’s address	8200 WEST SUNRISE BLVD., SUITE B-2, PLANTATION, FL, 33322

Plan administrator’s name and address

Administrator’s EIN	650401579
Plan administrator’s name	SAMUEL O. DORN, D.D.S., P.A.
Plan administrator’s address	8200 WEST SUNRISE BLVD., SUITE B-2, PLANTATION, FL, 33322
Administrator’s telephone number	9549666400

Signature of

Role	Plan administrator
Date	2010-09-22
Name of individual signing	SAMUEL O. DORN
Valid signature	Filed with authorized/valid electronic signature