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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-743177

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1. American Nurses Association PAC

    8515 Georgia Avenue
    Suite 400
    Silver Spring, MD 20910
    Email: Angela.Song@ana.org

2. Date: 08/25/2011

3. FEC Committee ID #: C00017525 This committee is a separate segregated fund. Its connected organization is a Labor Organization
     In addition, this committee is a Lobbyist/Registrant PAC.

Affiliated Committees/Organizations

American Nurses Association
8515 Georgia Ave
Ste 400
Silver Spring, Maryland 209103492
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Angela Song
8515 Georgia Ave #400
Silver Spring, MD 209103492
Title: Custodian of Records
Phone # (301) 628-5096

Treasurer:

Jennifer Davis
3511 Hastings Dr
Medina, Ohio 442566208
Title: Treasurer
Phone # (330) 294-0709

Designated Agent(s):

Rose Gonzalez
8515 Georgia Ave #400
Silver Spring, Maryland 209103492
Title: Designated Agent
Phone # (301) 628-5096

Banks or Depositories

Bank of America
PO Box 2485
Spokane, Washington 99210

Signed: Jennifer Davis
Date Signed: 08/25/2011

(End FEC FORM 1)

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