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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-136710

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1. Domino PAC

    1 Federal Street
    Yonkers, NY 10702

    NOTE: Address is different than previously reported

    Fax: 914-963-1467

2. Date: 01/24/2002

3. FEC Committee ID #: C00352591 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Custodian of Records:

Treasurer:

Mark Stevens
1 Federal Street
Yonkers, New York 10702
Title: Treasurer
Phone # (914) 963-2400

Designated Agent(s):

Banks or Depositories

Signed: Mark Stevens
Date Signed: 10/05/2004
Official Committee FAX: 914-963-1467

(End FEC FORM 1)

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