FEC Form 1 for AMERICAN SURGICAL HOSPITAL ASSOCIATION POLITICAL ACTION COMMITTEEForm 1 for AMERICAN SURGICAL HOSPITAL ASSOCIATION POLITICAL ACTION COMMITTEE

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-280734

1. AMERICAN SURGICAL HOSPITAL ASSOCIATION POLITICAL ACTION COMMITTEE

600 S. Cliff Ave.
Suite 106
Sioux Falls, SD 571045355
Fax: 6057312575
Email: molly@physicianhospitals.org

2. Date: 03/13/2007

3. FEC Committee ID #: C00394163 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

AMERICAN SURGICAL HOSPITAL ASSOCIATION
600 S. Cliff Avenue
Suite 106
Sioux Falls, South Dakota 571045355
Relationship: Connected Org.
Organization Type: Trade Association

Custodian of Records:

Molly Gutierrez
600 S. Cliff Ave.
Suite 106
Sioux Falls, SD 571045355
Title: Director
Phone # (605) 275-5349

Treasurer:

Douglas Johnson
600 S. Cliff Ave.
Suite 106
Sioux Falls, South Dakota 571045355
Phone # (605) 275-5349

Designated Agent(s):

Molly Gutierrez
600 S. Cliff Ave.
Suite 106
Sioux Falls, South Dakota 571045355
Title: Director
Phone # (605) 275-5349

Banks or Depositories

Wells Fargo Bank
P.O. Box 5128
Sioux Falls, South Dakota 571175128

Signed: Douglas Johnson
Date Signed: 03/13/2007
Official Committee FAX: 6057312575

(End FEC FORM 1)

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