SURGERY CLINIC OF COLUMBUS, PLLC

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2001-01-01
Business code	621111
Sponsor’s telephone number	6623284140
Plan sponsor’s mailing address	P.O. BOX 1404, COLUMBUS, MS, 39703
Plan sponsor’s address	P.O. BOX 1404, COLUMBUS, MS, 39703

Number of participants as of the end of the plan year

Active participants	0
Retired or separated participants receiving benefits	0
Other retired or separated participants entitled to future benefits	0
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits	0
Number of participants with account balances as of the end of the plan year	0
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	0

Signature of

Role	Plan administrator
Date	2015-02-20
Name of individual signing	PAUL HAWKINS
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2015-02-20
Name of individual signing	PAUL HAWKINS
Valid signature	Filed with authorized/valid electronic signature