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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-749811

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1. American Dental Association Political Action Committee

    1111 14th Street, NW
    Suite 1100
    Washington, DC 20005
    Email: taylorc@ada.org

2. Date: 10/19/2011

3. FEC Committee ID #: C00000729 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 DENTAL ASSOCIATION
1111 14TH STREET, NW
SUITE 1100
WASHINGTON, DC 20005
Affiliated Relationship Code: Connected Organization

California Dental PAC
PO Box 13749
Sacramento, California 95853
Affiliated Relationship Code: Affiliated Committee

Indiana Dental PAC
PO Box 2467
Indianapolis, Indiana 462062467
Affiliated Relationship Code: Affiliated Committee

New Jersey Dental PAC
One Dental Plaza
North Brunswick, New Jersey 089026020
Affiliated Relationship Code: Affiliated Committee

North Carolina Dental PAC
1600 Evans Road
Cary, North Carolina 27513
Affiliated Relationship Code: Affiliated Committee

Ohio Dental Association PAC
1370 Dublin Road
Columbus, Ohio 43215
Affiliated Relationship Code: Affiliated Committee

Custodian of Records:

Mrs. Cynthia Taylor
1111 14th Street, NW
Suite 1100
Washington, DC 20005
Title: Mgr, Mbrshp & Compli

Treasurer:

Dr Richard Huot
1111 14th Street NW
Suite 1100
Washington, DC 20005
Title: Dentist
Phone # (202) 898-2424

Designated Agent(s):

Banks or Depositories

CITIBANK
1101 PENNSYLVANIA AVENUE, NW
11TH FLOOR
WASHINGTON, DC 20004

Signed: Dr Richard Huot
Date Signed: 10/19/2011

FORM TEXT

(End FEC FORM 1)

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