FEC Form 1 for Blue Cross Blue Shield of Michigan PACForm 1 for Blue Cross Blue Shield of Michigan PAC

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-237270

1. Blue Cross Blue Shield of Michigan PAC

602 W. Ionia
Lansing, MI 48933
Fax: 517-371-7979

2. Date: 09/08/2006

3. FEC Committee ID #: C00084061 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

BluePAC (Blue Cross Blue Shield Association)
1310 G. St. NW
Washington, DC 20005
Relationship: Primary Affilliate
Organization Type: Membership Organization

Custodian of Records:

Treasurer:

Mr. Mark Cook
602 W. Ionia
Lansing, Michigan 48933
Title: Vice President Gove
Phone # (517) 371-7906

Designated Agent(s):

Banks or Depositories

Capitol National Bank
200 Washington Sq.
Lansing, Michigan 48909

Signed: Mr. Mark Cook
Date Signed: 09/08/2006
Official Committee FAX: 517-371-7979

(End FEC FORM 1)

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