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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1643837

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1. Genesis Healthcare Inc PAC

    101 E. State Street
    Kennett Square, PA 19348

    NOTE: Address is different than previously reported

    Email: johnny.patterson@genesishcc.com;michael.sherman@genesishcc.com

    NOTE: Email address is different than previously reported

2. Date: 10/18/2022

3. FEC Committee ID #: C00292094 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

Committee ID# C00292094
Genesis Healthcare Inc.
101 East State Street
Kennett Square, Pennsylvania 19348
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Michael Sherman
101 E. State Street
Kennett Square, PA 19348
Title: Treasuer
Phone # (610) 925-2281

Treasurer:

Michael Sherman
101 E. State Street
Kennett Square, Pennsylvania 19348
Title: Treasuer
Phone # (610) 925-2281

Designated Agent(s):

Johnny Patterson
101 E. State Street
Kennett Square, Pennsylvania 19348
Title: Secretary/ Asst. Tre
Phone # (213) 909-7644

Banks or Depositories

Wells Fargo Bank
400 Scarlett Road
Kennett Square, Pennsylvania 19348

Signed: Michael Sherman
Date Signed: 10/18/2022

(End FEC FORM 1)

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