FEC Form 1 for GENESIS HEALTHCARE CORPORATION POLITICAL ACTION COMMITTEEForm 1 for GENESIS HEALTHCARE CORPORATION POLITICAL ACTION COMMITTEE

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-409234

1. GENESIS HEALTHCARE CORPORATION POLITICAL ACTION COMMITTEE

101 EAST STATE STREET
KENNETT SQUARE, PA 19348
Email: Laurence.Lane@genesishcc.com

2. Date: 03/18/2009

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

Genesis HealthCare Corporation
101 E. State Street
Kennett Square, Pennsylvania 19348
Affiliated Relationship Code: Connected Organization

Custodian of Records:

LAURENCE F. LANE
1616 STEPHENS DRIVE
WAYNE, PA 19087
Title: Treasurer
Phone # (610) 444-8430

Treasurer:

LAURENCE F. LANE
1616 STEPHENS DRIVE
WAYNE, Pennsylvania 19087
Title: Treasurer
Phone # (610) 444-8430

Designated Agent(s):

Richard Pell
21 Greystone Drive
Shepherdstown, West Virginia 25443

Banks or Depositories

Mellon Bank
7th and Market Streets
Philadelphia, Pennsylvania 19101

Signed: LAURENCE F. LANE
Date Signed: 03/23/2009

(End FEC FORM 1)

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