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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1321107

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1. WISCONSIN HOSPITAL ASSOCIATION INC FEDERAL PAC DBA WISCONSIN HOSPITAL ASSOC FEDERAL PAC

    PO BOX 259038
    5510 Research Park Drive
    Madison, WI 537259038
    Email: bpotter@wha.org;abrenton@wha.org

    NOTE: Email address is different than previously reported

2. Date: 03/25/2019

3. FEC Committee ID #: C00422881 This committee is a separate segregated fund. Its connected organization is a Trade Association
     In addition, this committee is a Lobbyist/Registrant PAC.

Affiliated Committees/Organizations

Wisconsin Hospital Association
PO Box 259038
5510 Research Park Drive
Madison, Wisconsin 537259038
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Treasurer:

Mr. Brian Potter
5510 Research Park Drive
PO Box 259038
Madison, Wisconsin 537259038
Title: Senior Vice Presiden
Phone # (608) 274-1820

Designated Agent(s):

Andrew Brenton
PO Box 259038
5510 Research Park Drive
Madison, Wisconsin 537259038
Title: Assistant General Co
Phone # (608) 274-1820

Banks or Depositories

First Business Bank
401 Charmany Dr.
#100
Madison, Wisconsin 53719

Signed: Mr. Brian Potter
Date Signed: 03/25/2019

FORM TEXT-1

(End FEC FORM 1)

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