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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-960390

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1. FLORIDA HEALTH POLITICAL ACTION COMMITTEE (THE PAC OF BLUE CROSS & BLUE SHIELD OF FL, INC)

    P.O. Box 6936
    4800 Deerwood Campus Parkwy, DC3-4
    Jacksonville, FL 32246
    Email: eric.vidrine@bcbsfl.com;tom.giles@bcbsfl.com

    NOTE: Email address is different than previously reported

2. Date: 10/14/2014

3. FEC Committee ID #: C00161141 This committee is a separate segregated fund. Its connected organization is a Corporation
     In addition, this committee is a Lobbyist/Registrant PAC.

Affiliated Committees/Organizations

BLUE CROSS & BLUE SHIELD OF FL, INC
P.O. Box 6936
4800 Deerwood Campus Parkwy, DC3-4
Jacksonville, Florida 32246
Affiliated Relationship Code: Connected Organization

Blue Cross Blue Shield of Alabama
2 North Jackson St.
Suite 202
Montgomery, Alabama 36104
Affiliated Relationship Code: Affiliated Committee

HEALTHY GOVERNMENT COMMITTEE-THE POLIT
P.O. BOX 13466
PHOENIX, Arizona 85002
Affiliated Relationship Code: Affiliated Committee

BLUE SHIELD OF CALIFORNIA
50 BEALE STREET17-C356
SAN FRANCISCO, California 94105
Affiliated Relationship Code: Affiliated Committee

HAWAII MEDICAL SERVICE ASSOCIATION EMP
818 KEEAUMOKU STREET
HONOLULU, Hawaii 96814
Affiliated Relationship Code: Affiliated Committee

CAMBIA HEALTH SOLUTIONS INC PAC
200 SW MARKET STPO BOX 1271/MS E12
PORTLAND, Oregon 97207
Affiliated Relationship Code: Affiliated Committee

WELLMARK, INC. PAC (WELLPAC)
1331 GRAND AVENUESTA. 5W570
DES MOINES, Iowa 50309
Affiliated Relationship Code: Affiliated Committee

BLUE CROSS AND BLUE SHIELD OF NEBRASKA
7261 MERCY ROAD
PO BOX 3248
OMAHA, Nebraska 68180
Affiliated Relationship Code: Affiliated Committee

BLUE CROSS BLUE SHIELD OF SOUTH CAROLI
INTERSTATE 20 AT ALPINE ROAD
COLUMBIA, South Carolina 29214
Affiliated Relationship Code: Affiliated Committee

PREMERA BLUE CROSS POLITICAL ACTION CO
7001 220TH STREET SWMS 355
MOUNTLAKE TERRACE, Washington 98043
Affiliated Relationship Code: Affiliated Committee

CAREFIRST BLUECROSS BLUESHIELD ASSOCIA
10455 MILL RUN CIRCLE
OWINGS MILL, Maryland 21117
Affiliated Relationship Code: Affiliated Committee

FED CAREPAC, THE BLUE CROSS AND BLUE S
401 PARK DRIVE
LANDMARK CENTER
BOSTON, Massachusetts 02215
Affiliated Relationship Code: Affiliated Committee

BLUE CROSS BLUE SHIELD OF MICHIGAN PAC
232 S. CAPITOL
MC L10A
LANSING, Michigan 48933
Affiliated Relationship Code: Affiliated Committee

BLUE CROSS AND BLUE SHIELD OF KANSAS C
2301 MAIN STREET
KANSAS CITY, Missouri 64108
Affiliated Relationship Code: Affiliated Committee

BLUE CROSS AND BLUE SHIELD OF NORTH CA
P.O. Box 2291
Durham, North Carolina 27702
Affiliated Relationship Code: Affiliated Committee

HIGHMARK PAC OF HIGHMARK INC.
1800 Center Street
Camp Hill, Pennsylvania 17089
Affiliated Relationship Code: Affiliated Committee

BLUE CROSS VOICE THE POLITICAL ACTION
19 NORTH MAIN STREET
WILKES BARRE, Pennsylvania 18711
Affiliated Relationship Code: Affiliated Committee

INDEPENDENCE BLUE CROSS PAC (IBC PAC)
1901 MARKET STREET
PHILADELPHIA, Pennsylvania 19103
Affiliated Relationship Code: Affiliated Committee

BLUE CROSS AND BLUE SHIELD OF KANSAS,
1133 SW TOPEKA BLVD
CC:855 - B3
TOPEKA, Kansas 66629
Affiliated Relationship Code: Affiliated Committee

CAPITAL BLUEPAC, THE POLITICAL ACTION
PO BOX 60710
HARRISBURG, Pennsylvania 17177
Affiliated Relationship Code: Affiliated Committee

BLUEPAC - BLUE CROSS BLUE SHIELD ASSOC
1310 G STREET NW
WASHINGTON, DC 20005
Affiliated Relationship Code: Affiliated Committee

Custodian of Records:

Suzanne Horne
12876 Plummer Grant Rd
Jacksonville, FL 32258
Title: President
Phone # (904) 905-8720

Treasurer:

Mr. Gary M. Healy
285 Odoms Mill Blvd
Ponte Vedra Beach, Florida 32082
Title: Treasurer
Phone # (904) 905-4420

Designated Agent(s):

Banks or Depositories

Bank of America
9000 Southside Boulevard
Jacksonville, Florida 32256

Signed: Mr. Gary M. Healy
Date Signed: 10/14/2014

(End FEC FORM 1)

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