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  5. DAVID S. PETERSEN M.D., S.C.

DAVID S. PETERSEN M.D., S.C.

Company Details

Entity Name: DAVID S. PETERSEN M.D., S.C.
Jurisdiction: Illinois
Entity Type: Corporation - Domestic BCA
Status: Dissolved
Date Formed: 15 Apr 1999
Date of Dissolution: 13 Sep 2019
Company Number: CORP_60447934
File Number: 60447934
Type of Business: Incorporated under the Medical Corporation Act
Date Status Change: 13 Sep 2019
Place of Formation: ILLINOIS

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
DAVID S. PETERSEN, M.D., S.C. PROFIT SHARING PLAN 2014 364287616 2015-07-18 DAVID S. PETERSEN, M.D., S.C. 6
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1999-07-01
Business code 621111
Sponsor’s telephone number 3097649790
Plan sponsor’s address 2121 1ST STREET A, MOLINE, IL, 61265
DAVID S. PETERSEN, M.D., S.C. PROFIT SHARING PLAN 2013 364287616 2014-10-02 DAVID S. PETERSEN, M.D., S.C. 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1999-07-01
Business code 621111
Sponsor’s telephone number 3097649790
Plan sponsor’s address 2121 1ST STREET A, MOLINE, IL, 61265

Signature of
Role Plan administrator
Date 2014-10-02
Name of individual signing DAVID S. PETERSEN
Valid signature Filed with authorized/valid electronic signature
DAVID S. PETERSEN, M.D., S.C. PROFIT SHARING PLAN 2012 364287616 2013-10-10 DAVID S. PETERSEN, M.D., S.C. 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1999-07-01
Business code 621111
Sponsor’s telephone number 3097649790
Plan sponsor’s address 2121 1ST STREET A, MOLINE, IL, 61265

Signature of
Role Plan administrator
Date 2013-10-10
Name of individual signing DAVID S. PETERSEN
Valid signature Filed with authorized/valid electronic signature
DAVID S. PETERSEN, M.D., S.C. PROFIT SHARING PLAN 2011 364287616 2012-10-30 DAVID S. PETERSEN, M.D., S.C. 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1999-07-01
Business code 621111
Sponsor’s telephone number 3097649790
Plan sponsor’s address 2121 1ST STREET A, MOLINE, IL, 61265

Plan administrator’s name and address
Administrator’s EIN 364287616
Plan administrator’s name DAVID S. PETERSEN, M.D., S.C.
Plan administrator’s address 2121 1ST STREET A, MOLINE, IL, 61265
Administrator’s telephone number 3097649790

Signature of
Role Plan administrator
Date 2012-10-30
Name of individual signing DAVID S PETERSEN
Valid signature Filed with authorized/valid electronic signature
DAVID S. PETERSEN, M.D., S.C. PROFIT SHARING PLAN 2011 364287616 2012-10-16 DAVID S. PETERSEN, M.D., S.C. 4
Three-digit plan number (PN) 001
Effective date of plan 1999-07-01
Business code 621111
Sponsor’s telephone number 3097649790
Plan sponsor’s address 2121 1ST STREET A, MOLINE, IL, 61265

Plan administrator’s name and address
Administrator’s EIN 364287616
Plan administrator’s name DAVID S. PETERSEN, M.D., S.C.
Plan administrator’s address 2121 1ST STREET A, MOLINE, IL, 61265
Administrator’s telephone number 3097649790

Signature of
Role Plan administrator
Date 2012-10-16
Name of individual signing D
Valid signature Filed with authorized/valid electronic signature
DAVID S. PETERSEN, M.D., S.C. PROFIT SHARING PLAN 2010 364287616 2011-10-14 DAVID S. PETERSEN, M.D., S.C. 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1999-07-01
Business code 621111
Sponsor’s telephone number 3097649790
Plan sponsor’s address 2121 1ST STREET A, MOLINE, IL, 61265

Plan administrator’s name and address
Administrator’s EIN 364287616
Plan administrator’s name DAVID S. PETERSEN, M.D., S.C.
Plan administrator’s address 2121 1ST STREET A, MOLINE, IL, 61265
Administrator’s telephone number 3097649790

Signature of
Role Plan administrator
Date 2011-10-14
Name of individual signing DAVID S. PETERSEN
Valid signature Filed with authorized/valid electronic signature
DAVID S. PETERSEN, M.D., S.C. PROFIT SHARING PLAN 2009 364287616 2010-07-29 DAVID S. PETERSEN, M.D., S.C. 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1999-07-01
Business code 621111
Sponsor’s telephone number 3097649790
Plan sponsor’s address 2121 1ST STREET A, MOLINE, IL, 61265

Plan administrator’s name and address
Administrator’s EIN 364287616
Plan administrator’s name DAVID S. PETERSEN, M.D., S.C.
Plan administrator’s address 2121 1ST STREET A, MOLINE, IL, 61265
Administrator’s telephone number 3097649790

Signature of
Role Plan administrator
Date 2010-07-29
Name of individual signing DAVID S. PETERSEN
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2010-07-29
Name of individual signing DAVID S. PETERSEN
Valid signature Filed with authorized/valid electronic signature

Agent

Name and Address Role Appointment Date
DANIEL CHURCHILL, 1610 5TH AVE, MOLINE, 61265, ROCK ISLAND Agent 1999-04-15

President

Name and Address Role
DAVID S PETERSEN, 3525 14TH STROCK ISLAND 61201 President

Shares

Class Series Voting Rights Authorized Shares Issued Shares Par Value
COMMON No data Voting Rights 10000 10000 No data

Related by officers

DANIEL CHURCHILL, 1610 5TH AVE, MOLINE, 61265, ROCK ISLAND

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Related by address

No related companies by address

Date of last update: 16 Jan 2025

Sources: Illinois Office of the Secretary of State

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