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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-238606

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1. American Health Care Association Political Action Committee

    1201 L Street NW
    Washington, DC 20005
    Email: cmorton@ahca.org

2. Date: 09/19/2006

3. FEC Committee ID #: C00006080 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Custodian of Records:

Treasurer:

Robert Van Dyk
1201 L Street NW
Washington, DC 20005

Designated Agent(s):

Banks or Depositories

BB&T
PO Box 819
Wilson, North Carolina 27894

Signed: Robert Van Dyk
Date Signed: 09/19/2006

(End FEC FORM 1)

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