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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-376299

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1. Indiana State Medical Association Political Action Committee

    NOTE:Commmittee Name is different than previously reported

    322 Canal Walk, Canal Level
    Indianapolis, IN 46202
    Fax: 3172612221
    Email: sgrant@ismanet.org

2. Date: 10/23/2008

3. FEC Committee ID #: C00000638 This committee is a separate segregated fund. Its connected organization is a Membership Organization

Affiliated Committees/Organizations

Indiana State Medical Association
322 Canal Walk, Canal Level
Indianapolis, Indiana 46202
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Treasurer:

Vidya Kora, M.D.
322 Canal Walk, Canal Level
Indianapolis, Indiana 46202
Title: Treasurer
Phone # (317) 261-2060

Designated Agent(s):

Banks or Depositories

Huntington National Bank
P.O. Box 6054
Indianapolis, Indiana 46206

Signed: Vidya Kora, M.D.
Date Signed: 10/23/2008
Official Committee FAX: 3172612221

(End FEC FORM 1)

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