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First State Bank

Company Details

Name: First State Bank
Jurisdiction: MISSISSIPPI
Business Type: Profit Corporation
Status: Withdrawn
Effective Date: 11 Aug 2004 (20 years ago)
Business ID: 859414
State of Incorporation: TENNESSEE
Fictitious names: First Auto

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
FIRST STATE BANK WELFARE BENEFIT PLAN 2021 640659655 2022-04-20 FIRST STATE BANK 155
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address PO BOX 506, WAYNESBORO, MS, 393670506
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Number of participants as of the end of the plan year
Active participants 153

Signature of
Role Plan administrator
Date 2022-04-20
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
FIRST STATE BANK WELFARE BENEFIT PLAN 2020 640659655 2021-05-19 FIRST STATE BANK 160
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address PO BOX 506, WAYNESBORO, MS, 393670506
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Number of participants as of the end of the plan year
Active participants 155

Signature of
Role Plan administrator
Date 2021-05-18
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2021-05-18
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
FIRST STATE BANK WELFARE BENEIT PLAN 2019 640659655 2020-02-24 FIRST STATE BANK 162
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address PO BOX 506, WAYNESBORO, MS, 393670506
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Number of participants as of the end of the plan year
Active participants 160

Signature of
Role Plan administrator
Date 2020-02-24
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
FIRST STATE BANK WELFARE BENEFIT PLAN 2018 640659655 2019-05-15 FIRST STATE BANK 161
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address PO BOX 506, WAYNESBORO, MS, 393670506
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Number of participants as of the end of the plan year
Active participants 162

Signature of
Role Plan administrator
Date 2019-05-15
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2019-05-15
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
FIRST STATE BANK WELFARE BENEFIT PLAN 2017 640659655 2018-07-17 FIRST STATE BANK 159
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address PO BOX 506, WAYNESBORO, MS, 393670506
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Number of participants as of the end of the plan year
Active participants 161

Signature of
Role Plan administrator
Date 2018-07-17
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
FIRST STATE BANK WELFARE BENEFIT PLAN 2016 640659655 2017-06-07 FIRST STATE BANK 156
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address PO BOX 506, WAYNESBORO, MS, 393670506
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Number of participants as of the end of the plan year
Active participants 159

Signature of
Role Plan administrator
Date 2017-06-06
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2017-06-06
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
FIRST STATE BANK WELFARE BENEFIT PLAN 2015 640659655 2016-05-09 FIRST STATE BANK 128
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address PO BOX 506, WAYNESBORO, MS, 393670506
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Number of participants as of the end of the plan year
Active participants 156

Signature of
Role Plan administrator
Date 2016-05-09
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
FIRST STATE BANK WELFARE BENEFIT PLAN 2014 640659655 2015-10-13 FIRST STATE BANK 125
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Number of participants as of the end of the plan year
Active participants 128

Signature of
Role Plan administrator
Date 2015-10-13
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
FIRST STATE BANK WELFARE BENEFIT PLAN 2013 640659655 2014-05-21 FIRST STATE BANK 126
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Number of participants as of the end of the plan year
Active participants 125

Signature of
Role Plan administrator
Date 2014-05-21
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
FIRST STATE BANK WELFARE BENEFIT PLAN 2012 640659655 2013-07-01 FIRST STATE BANK 127
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Number of participants as of the end of the plan year
Active participants 126

Signature of
Role Plan administrator
Date 2013-07-01
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2013/03/21/20130321090534P040050270885001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2004-01-01
Business code 522110
Sponsor’s telephone number 6622524211
Plan sponsor’s address P.O. BOX 580, HOLLY SPRINGS, MS, 386350580

Signature of
Role Plan administrator
Date 2013-03-21
Name of individual signing CHARLES MCCLATCHY, JR.
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2013-03-21
Name of individual signing CHARLES MCCLATCHY, JR.
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2012/06/05/20120605133225P030002438278001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 127

Signature of
Role Plan administrator
Date 2012-06-05
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/30/20110830141635P040561119776001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 124

Signature of
Role Plan administrator
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/30/20110830141443P030121362065001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 123

Signature of
Role Plan administrator
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/30/20110830141413P030566413712001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 116

Signature of
Role Plan administrator
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/30/20110830141344P040124706625001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 117

Signature of
Role Plan administrator
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/30/20110830141321P030121361681001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 111

Signature of
Role Plan administrator
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/30/20110830141257P030566410608001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 108

Signature of
Role Plan administrator
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/30/20110830141233P030038738695001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 112

Signature of
Role Plan administrator
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/30/20110830141209P030038738647001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 114

Signature of
Role Plan administrator
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/30/20110830141128P040124705905001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 101

Signature of
Role Plan administrator
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/30/20110830141055P030121361169001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 92

Signature of
Role Plan administrator
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/30/20110830141009P040561104960001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 97

Signature of
Role Plan administrator
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/30/20110830140349P030121359009001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 94

Signature of
Role Plan administrator
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/30/20110830135805P040561077008001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 83

Signature of
Role Plan administrator
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/30/20110830141604P040561118640001.pdf
Three-digit plan number (PN) 502
Effective date of plan 1997-01-01
Business code 522110
Sponsor’s telephone number 6017353124
Plan sponsor’s mailing address P O BOX 506, WAYNESBORO, MS, 39367
Plan sponsor’s address 708 AZALEA DRIVE, WAYNESBORO, MS, 39367

Plan administrator’s name and address
Administrator’s EIN 640659655
Plan administrator’s name FIRST STATE BANK
Plan administrator’s address P O BOX 506, WAYNESBORO, MS, 39367
Administrator’s telephone number 6017353124

Number of participants as of the end of the plan year
Active participants 125

Signature of
Role Plan administrator
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-08-30
Name of individual signing KRISTY DAVIS
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
Little, Jim Agent 207 S. Jackson St., Crystal Springs, MS 39059

Treasurer

Name Role Address
Alan Haefele Treasurer 115 West Washington Ave, Union City, TN 38261

Secretary

Name Role Address
Kathy Barber Secretary 115 West Washington Ave, Union City, TN 38261

Director

Name Role Address
Mike Swaim Director 319 South Lindell, Martin, TN 38237
Nick Dunagan Director 112 University Street, Martin, TN 38237
Keith Farmer Director 516 Old Troy Road, Martin, TN 38237

Filings

Type Status Filed Date Description
Withdrawal Filed 2016-06-28 Withdrawal For First State Bank
Formation Form Filed 2004-08-11 Formation

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Little, Jim

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Date of last update: 08 Jan 2025

Sources: Mississippi Secretary of State

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