FEC Form 1 for GENTIVA HEALTH SERVICES INC PAC GENTIVAPACForm 1 for GENTIVA HEALTH SERVICES INC PAC GENTIVAPAC

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-410090

1. GENTIVA HEALTH SERVICES INC PAC GENTIVAPAC

3 HUNTINGTON QUADRANGLE
SUITE 200S
MELVILLE, NY 117474627
Email: jeff.copeland@gentiva.com

2. Date: 03/27/2009

3. FEC Committee ID #: C00407080 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

GENTIVA HEALTH SERVICES INC.
3 HUNTINGTON QUADRANGLE
SUITE 200S
MELVILLE, New York 11747
Affiliated Relationship Code: Connected Organization

Custodian of Records:

John Potapchuk
3 Huntington Quadrangle
Suite 200S
Melville, NY 11747
Title: Treasurer
Phone # (631) 501-7035

Treasurer:

John Potapchuk
3 Huntington Quadrangle
Suite 200S
Melville, New York 11747
Title: Treasurer
Phone # (631) 501-7035

Designated Agent(s):

Banks or Depositories

Bank of America
P O Box 798
Wichita, Kansas 67201

Signed: John Potapchuk
Date Signed: 03/27/2009

(End FEC FORM 1)

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