Union Smiles, Inc.

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2009-01-01
Business code	621210
Sponsor’s telephone number	8593840393
Plan sponsor’s DBA name	DERRINGER FAMILY DENTISTRY
Plan sponsor’s address	8667 US HIGHWAY 42, UNION, KY, 410918759

Signature of

Role	Plan administrator
Date	2018-08-10
Name of individual signing	DAYNE CLARK
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2009-01-01
Business code	621210
Sponsor’s telephone number	8593840393
Plan sponsor’s DBA name	DERRINGER FAMILY DENTISTRY
Plan sponsor’s address	8667 US HIGHWAY 42 STE 100, UNION, KY, 410918759

Signature of

Role	Plan administrator
Date	2017-11-15
Name of individual signing	DAYNE CLARK
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2017-11-15
Name of individual signing	DAYNE CLARK
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2009-01-01
Business code	621210
Sponsor’s telephone number	8593840393
Plan sponsor’s DBA name	DERRINGER FAMILY DENTISTRY
Plan sponsor’s address	8667 US HIGHWAY 42 STE 100, UNION, KY, 410918759

Signature of

Role	Plan administrator
Date	2016-05-10
Name of individual signing	DAYNE CLARK
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2009-01-01
Business code	621210
Sponsor’s telephone number	8593840393
Plan sponsor’s DBA name	DERRINGER MCGLONE FAMILY DENTISTRY
Plan sponsor’s address	8667 US 42, SUITE 100, UNION, KY, 41094

Signature of

Role	Plan administrator
Date	2015-05-12
Name of individual signing	DAYNE CLARK
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2009-01-01
Business code	621210
Sponsor’s telephone number	8593840393
Plan sponsor’s DBA name	DERRINGER MCGLONE FAMILY DENTISTRY
Plan sponsor’s address	8667 US 42, SUITE 100, UNION, KY, 41094

Signature of

Role	Plan administrator
Date	2014-05-14
Name of individual signing	DAYNE CLARK
Valid signature	Filed with authorized/valid electronic signature