FAMILY MEDICAL SPECIALTY CLINIC, PLLC

File	View Page
Three-digit plan number (PN)	501
Effective date of plan	2023-03-01
Business code	621491
Sponsor’s telephone number	6069300199
Plan sponsor’s address	12 JACKSON HTS, JACKSON, KY, 41339

Plan administrator’s name and address

Administrator’s EIN	846429706
Plan administrator’s name	SHAWNA BURTON
Plan administrator’s address	464 CHENAULT RD, FRANKFORT, KY, 40601
Administrator’s telephone number	5026954700

Signature of

Role	Plan administrator
Date	2023-12-27
Name of individual signing	SHAWNA BURTON
Valid signature	Filed with authorized/valid electronic signature