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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-442234

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1. American Health Care Association Political Action Committee

    1201 L Street, NW
    Washington, DC 20005
    Email: saman@ahca.org

2. Date: 12/16/2009

3. FEC Committee ID #: C00006080 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

Committee ID# C00006080
American Health Care Association
1201 L Street, NW
Washington, DC 20005
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Ms. Stacie S. Aman
1201 L Street, NW
Washington, DC 20005
Title: Director, AHCA-PAC
Phone # (202) 898-2856

Treasurer:

Mr. Leonard Russ
1201 L Street, NW
Washington, DC 20005
Title: Treasurer
Phone # (202) 898-2856

Designated Agent(s):

Ms. Stacie S. Aman
1201 L Street, NW
Washington, DC 20005
Title: Direcotr, AHCA-PAC
Phone # (202) 898-2856

Banks or Depositories

BB&T
P.O. Box 819
Wilson, North Carolina 27894

Signed: Mr. Leonard Russ
Date Signed: 12/16/2009

(End FEC FORM 1)

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