FEC Form 1 for Florida Dental Political Action CommitteeForm 1 for Florida Dental Political Action Committee

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-287486

1. Florida Dental Political Action Committee

1111 East Tennessee Street
Tallahassee, FL 32308
Fax: 850-561-0504
Email: jmoore@floridadental.org

2. Date: 05/02/2007

3. FEC Committee ID #: C00013672 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Florida Dental Association Inc.
1111 East Tennessee Street
Tallahassee, Florida 32308
Relationship: Connected
Organization Type: Membership Organization

Custodian of Records:

Jack A. Moore
1111 East Tennessee Street
Tallahassee, FL 32308
Title: CFO
Phone # (850) 681-3629

Treasurer:

Dr. David L. Russell
14 Racetrack Road NW
Fort Walton Beach, Florida 325471642
Title: Treasurer
Phone # (850) 863-3195

Designated Agent(s):

James Walton, III
1280 Timberlane Road
Tallahassee, Florida 32312
Title: Chairperson

Banks or Depositories

People's First Community Bank
107 East College Avenue
Tallahassee, Florida 32301

Signed: Dr. David L. Russell
Date Signed: 05/02/2007
Official Committee FAX: 850-561-0504

FORM TEXT

(End FEC FORM 1)

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