FEC Form 1 for OREGON MEDICAL POLITICAL ACTION COMMITTEEForm 1 for OREGON MEDICAL POLITICAL ACTION COMMITTEE

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-157137

1. OREGON MEDICAL POLITICAL ACTION COMMITTEE

5210 SW CORBETT AVENUE
PORTLAND, OR 972393897
Fax: 5032417148
Email: sarita@theoma.org

2. Date: 12/28/2004

3. FEC Committee ID #: C00035766 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Committee ID# C00000422
AMPAC
1101 VERMONT AVENUE NW
12TH FLOOR
WASHINGTON, DC 20005
Relationship: Affiliated
Organization Type: Membership Organization

Custodian of Records:

Sarita Marfin
OMA
5210 SW Corbett Ave
Portland, OR 97239
Title: Assistant
Phone # (503) 595-5151

Treasurer:

DAVID COUTIN
OREGON MEDICAL ASSOCIATION
5210 SW CORBETT AVENUE
PORTLAND, Oregon 97239
Title: Treasurer
Phone # (503) 226-1555

Designated Agent(s):

Banks or Depositories

US Bank
POB 1800
St Paul, Minnesota 551010800

Signed: DAVID COUTIN
Date Signed: 12/28/2004
Official Committee FAX: 5032417148

(End FEC FORM 1)

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