FEC Form 1 for AMERICAN MEDICAL ASSOCIATION POLITICAL ACTION COMMITTEEForm 1 for AMERICAN MEDICAL ASSOCIATION POLITICAL ACTION COMMITTEE

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-714697

1. AMERICAN MEDICAL ASSOCIATION POLITICAL ACTION COMMITTEE

25 Massachusetts Ave, NW
Suite 600
Washington, DC 20001
Email: ampaconline@ama-assn.org

2. Date: 02/16/2011

3. FEC Committee ID #: C00000422 This committee is a separate segregated fund. Its connected organization is a Membership Organization
In addition, this committee is a Lobbyist/Registrant PAC.

Affiliated Committees/Organizations

AMERICAN MEDICAL ASSOCIATION
515 NORTH STATE STREET
CHICAGO, Illinois 60654
Affiliated Relationship Code: Connected Organization

ALABAMA MEDICAL POLITICAL ACTION COMMI
PO BOX 22
MONTGOMERY, Alabama 36101
Affiliated Relationship Code: Affiliated Committee

ALASKA STATE MEDICAL ASSOCIATION POLIT
4107 LAUREL STREET
ANCHORAGE, Alaska 99508
Affiliated Relationship Code: Affiliated Committee

ARKANSAS MEDICAL SOCIETY POLITICAL ACT
PO BOX 55088
LITTLE ROCK, Arkansas 77215
Affiliated Relationship Code: Affiliated Committee

CALIFORNIA MEDICAL ASSOCIATION POLITIC
1201 J STREET
SUITE 375
SACRAMENTO, California 95814
Affiliated Relationship Code: Affiliated Committee

HAWAII MEDICAL POLITICAL ACTION COMMIT
1360 S. BERETANIA STREET
SUITE 200
HONOLULU, Hawaii 96814
Affiliated Relationship Code: Affiliated Committee

ILLINOIS STATE MEDICAL SOCIETY POLITIC
20 NORTH MICHIGAN AVENUE
SUITE 700
CHICAGO, Illinois 60602
Affiliated Relationship Code: Affiliated Committee

INDIANA STATE MEDICAL ASSOCIATION POLI
322 CANAL WALK
CANAL LEVEL
INDIANAPOLIS, Indiana 46202
Affiliated Relationship Code: Affiliated Committee

IOWA MEDICAL SOCIETY POLITICAL ACTION
1001 GRAND AVENUE
WEST DES MOINES, Iowa 50265
Affiliated Relationship Code: Affiliated Committee

KANSAS MEDICAL SOCIETY POLITICAL ACTIO
623 SW 10TH AVENUE
TOPEKA, Kansas 66612
Affiliated Relationship Code: Affiliated Committee

KENTUCKY MEDICAL ASSOCIATION POLITICAL
4965 U.S. HIGHWAY 42
SUITE 2000
LOUISVILLE, Kentucky 40222
Affiliated Relationship Code: Affiliated Committee

LOUISIANA STATE MEDICAL SOCIETY POLITI
6767 PERKINS ROAD
SUITE 100
BATON ROUGE, Louisiana 70808
Affiliated Relationship Code: Affiliated Committee

MAINE MEDICAL POLITICAL ACTION COMMITT
PO BOX 190
MANCHESTER, Maine 04351
Affiliated Relationship Code: Affiliated Committee

MICHIGAN DOCTORS POLITICAL ACTION COMM
PO BOX 769
EAST LANSING, Michigan 48826
Affiliated Relationship Code: Affiliated Committee

NEBRASKA MEDICAL ASSOCIATION POLITICAL
233 S. 13TH STREET
SUITE 1200
LINCOLN, Nebraska 68508
Affiliated Relationship Code: Affiliated Committee

NEVADA MEDICAL POLITICAL ACTION COMMIT
3660 BAKER LANE
SUITE 101
RENO, Nevada 89509
Affiliated Relationship Code: Affiliated Committee

NEW HAMPSHIRE MEDICAL SOCIETY PHYSICIA
7 NORTH STATE STREET
CONCORD, New Hampshire 03301
Affiliated Relationship Code: Affiliated Committee

NEW JERSEY MEDICAL POLITICAL ACTION CO
2 PRINCESS ROAD
LAWRENCEVILLE, New Jersey 08648
Affiliated Relationship Code: Affiliated Committee

NEW MEXICO MEDICAL SOCIETY POLITICAL A
7770 JEFFERSON, NE
SUITE 400
ALBUQUERQUE, New Mexico 87109
Affiliated Relationship Code: Affiliated Committee

NORTH CAROLINA MEDICAL SOCIETY FEDERAL
PO BOX 25834
RALEIGH, North Carolina 27611
Affiliated Relationship Code: Affiliated Committee

NORTH DAKOTA MEDICAL ASSOCIATION POLIT
PO BOX 1198
BISMARCK, North Dakota 58502
Affiliated Relationship Code: Affiliated Committee

OHIO STATE MEDICAL ASSOCIATION POLITIC
3401 MILL RUN DRIVE
HILLIARD, Ohio 43026
Affiliated Relationship Code: Affiliated Committee

OREGON MEDICAL ASSOCIATION POLITICAL A
11740 SW 68TH PARKWAY
SUITE 100
PORTLAND, Oregon 97223
Affiliated Relationship Code: Affiliated Committee

PENNSYLVANIA MEDICAL SOCIETY POLITICAL
PO BOX 8820
HARRISBURG, Pennsylvania 17015
Affiliated Relationship Code: Affiliated Committee

RHODE ISLAND MEDICAL POLITICAL ACTION
235 PROMENADE STREET
SUITE 500
PROVIDENCE, Rhode Island 02908
Affiliated Relationship Code: Affiliated Committee

SOUTH DAKOTA STATE MEDICAL ASSOCIATION
2600 W. 49TH STREET
SUITE 200
SIOUX FALLS, South Dakota 57105
Affiliated Relationship Code: Affiliated Committee

TEXAS MEDICAL ASSOCIATION POLITICAL AC
401 WEST 15TH STREET
AUSTIN, Texas 78701
Affiliated Relationship Code: Affiliated Committee

UTAH MEDICAL POLITICAL ACTION COMMITTE
310 EAST 4500 SOUTH
SUITE 500
SALT LAKE CITY, Utah 84107
Affiliated Relationship Code: Affiliated Committee

WYOMING MEDICAL POLITICAL ACTION COMMI
PO BOX DRAWER 4009
CHEYENNE, Wyoming 82003
Affiliated Relationship Code: Affiliated Committee

Custodian of Records:

Kevin Walker
25 Massachusetts Avenue, NW
Suite 600
Washington, DC 20001
Title: VP Political Affairs
Phone # (202) 789-7467

Treasurer:

Kevin Walker
25 Massachusetts Ave, NW
Suite 600
Washington, DC 20001
Title: VP Political Affairs
Phone # (202) 789-7467

Designated Agent(s):

MICHAEL CYS
7307 LAKETREE DRIVE
FAIRFAX STATION, Virginia 22039
Title: ASSISTANT TREASURER
Phone # (202) 789-7457

NICOLE LONETTO
4603 MANOR DRIVE
ALEXANDRIA, Virginia 22309
Title: ASSISTANT TREASURER
Phone # (202) 789-7433

JOHN W POOLE, MD
240 SUNSET AVENUE
RIDGEWOOD, New Jersey 07450
Title: SECRETARY
Phone # (201) 445-2923

Banks or Depositories

PNC ADVISORS
PO BOX 96211
WASHINGTON, DC 20090

PNC BANK
PO BOX 1912
WASHINGTON, DC 20074

Signed: Kevin Walker
Date Signed: 02/16/2010

(End FEC FORM 1)

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