FEC Form 1 for Indiana Dental PACForm 1 for Indiana Dental PAC

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-328390

1. Indiana Dental PAC

401 W Michigan St
Suite 1000
Indianapolis, IN 46204
Fax: 3176342612
Email: IDPAC@indental.org

2. Date: 03/21/2008

3. FEC Committee ID #: C00082636 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Committee ID# C00000729
AMERICAN DENTAL POLITICAL ACTION CMTE.
1111 14th Street NW
Suite 1100
Washington, DC 20005
Relationship: related Dental PAC
Organization Type: Trade Association

Indiana Dental Association
401 W Michigan St, Ste 1000
Indianapolis, Indiana 46204
Relationship: PAC sponsoring org.
Organization Type: Trade Association

Custodian of Records:

Mr. Timothy Murphy
401 W Michigan St
Indianapolis, IN 46204
Title: CFO
Phone # (317) 340-1713

Treasurer:

Raymond Maddox
1200 N Walnut St
Hartford City, Indiana 47348
Title: Treasurer
Phone # (317) 634-2610

Designated Agent(s):

Raymond Maddox
1200 N Walnut St
Hartford City, Indiana 47348
Title: Treasurer
Phone # (317) 634-2610

Banks or Depositories

PaceSetter Bank
1515 N Walnut
Hartford City, Indiana 47348

Citigroup Global Markets / Smith Barne
111 Monument Circle
Indianapolis, Indiana 46204

Signed: Mr. Timothy Murphy
Date Signed: 03/21/2008
Official Committee FAX: 3176342612

(End FEC FORM 1)

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