ROBERT W. POLANCICH, D.M.D., P.S.C.

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1985-12-31
Business code	621210
Sponsor’s telephone number	8592788419
Plan sponsor’s address	1807 NICHOLASVILLE RD., LEXINGTON, KY, 40503

Signature of

Role	Plan administrator
Date	2013-09-30
Name of individual signing	ROBERT W. POLANCICH, D.M.D.
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1985-12-31
Business code	621210
Sponsor’s telephone number	8592788419
Plan sponsor’s address	1807 NICHOLASVILLE RD., LEXINGTON, KY, 40503

Plan administrator’s name and address

Administrator’s EIN	611148078
Plan administrator’s name	ROBERT W. POLANCICH, D.M.D., P.S.C.
Plan administrator’s address	1807 NICHOLASVILLE RD., LEXINGTON, KY, 40503
Administrator’s telephone number	8592788419

Signature of

Role	Plan administrator
Date	2012-06-18
Name of individual signing	ROBERT W. POLANCICH, D.M.D.
Valid signature	Filed with authorized/valid electronic signature