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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-912626

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1. American Nurses Association PAC

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

2. Date: 03/19/2014

3. FEC Committee ID #: C00017525 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

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

Custodian of Records:

Angela Song
3015 Nicosh Cir
Falls Church, VA 220421235
Title: Custodian of Records
Phone # (301) 628-5096

Treasurer:

Jan C. Polizzi
5953 Shortleaf Ct
Saint Louis, Missouri 631284306
Title: Treasurer
Phone # (314) 842-0669

Designated Agent(s):

Banks or Depositories

Bank of America
PO Box 2485
Spokane, Washington 99210

Signed: Jan C. Polizzi
Date Signed: 03/19/2014
Official Committee URL: www.ana-pac.org

(End FEC FORM 1)

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