Legacy Dental, P.C.

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Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	621210
Sponsor’s telephone number	2565433747
Plan sponsor’s address	108 FOUNTAIN AVE., GADSDEN, AL, 35901

Signature of

Role	Plan administrator
Date	2024-01-05
Name of individual signing	ANDREW P. BRUNSON

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Three-digit plan number (PN)	003
Effective date of plan	1999-01-01
Business code	621210
Sponsor’s telephone number	2565439572
Plan sponsor’s address	311 S. 5TH ST., STE. A, GADSDEN, AL, 359014278

Plan administrator’s name and address

Administrator’s EIN	631175067
Plan administrator’s name	SAMUEL S. BREWER, D.M.D., P.C.
Plan administrator’s address	311 S. 5TH ST., STE. A, GADSDEN, AL, 359014278
Administrator’s telephone number	2565439572

Signature of

Role	Plan administrator
Date	2011-03-11
Name of individual signing	SAMUEL S. BREWER, PRESIDENT

File	View Page
Three-digit plan number (PN)	003
Effective date of plan	1999-01-01
Business code	621210
Sponsor’s telephone number	2565439572
Plan sponsor’s address	311 S. 5TH ST., STE. A, GADSDEN, AL, 359014278

Plan administrator’s name and address

Administrator’s EIN	631175067
Plan administrator’s name	SAMUEL S. BREWER, D.M.D., P.C.
Plan administrator’s address	311 S. 5TH ST., STE. A, GADSDEN, AL, 359014278
Administrator’s telephone number	2565439572

Signature of

Role	Plan administrator
Date	2010-08-19
Name of individual signing	SAMUEL S. BREWER, PRESIDENT