FEC Form 1 for BROOKE HOLDINGS INC AND JACKSON NATIONAL LIFE INSURANCE COMPANY SEPARATE SEGREGATED FUNDForm 1 for BROOKE HOLDINGS INC AND JACKSON NATIONAL LIFE INSURANCE COMPANY SEPARATE SEGREGATED FUND

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-29142

1. BROOKE HOLDINGS INC AND JACKSON NATIONAL LIFE INSURANCE COMPANY SEPARATE SEGREGATED FUND

1 Corporate Way
LANSING, MI 48951
Email: lynn.seaks@jnli.com

2. Date: 03/07/2002

3. FEC Committee ID #: C00254953 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Custodian of Records:

Ms Lynn Denise Seaks
6101 Steele Highway
Eaton Rapids, MI 48827
Title: Assistant Treasurer
Phone # (517) 367-3612

Treasurer:

Ms Lynn Denise Seaks
6101 Steele Highway
Eaton Rapids, Michigan 48827
Title: Assistant Treasurer
Phone # (517) 367-3612

Designated Agent(s):

Banks or Depositories

Signed: Ms Lynn Denise Seaks
Date Signed: 03/07/2002

(End FEC FORM 1)

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