RICHARD E. FELLOWS, D.D.S., P.C.

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2008-01-01
Business code	621210
Sponsor’s telephone number	2082374357
Plan sponsor’s DBA name	OLYMPUS FAMILY DENTAL
Plan sponsor’s address	1598 DELPHIC WAY, SUITE B, POCATELLO, ID, 83201

Signature of

Role	Plan administrator
Date	2017-10-12
Name of individual signing	DANIELLE MABEY
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2017-10-12
Name of individual signing	DANIELLE MABEY
Valid signature	Filed with authorized/valid electronic signature