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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-758202

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1. LOCAL 500 PAC

    3460 NORTH DELAWARE AVE
    SUITE 301
    PHILADELPHIA, PA 19134
    Email: l500fooddr@aol.com

2. Date: 01/19/2012

3. FEC Committee ID #: C00094904 This committee is a separate segregated fund. Its connected organization is a Labor Organization

Affiliated Committees/Organizations

Teamsters Local Union 500
3460 N Delaware Ave
Suite 301
Philadlephia, Pennsylvania 19134
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Kevin Hagerty
Title: Treasurer
Phone # (215) 291-9540

Treasurer:

Kevin Hagerty
, ____
Title: Treasurer
Phone # (215) 291-9540

Designated Agent(s):

Banks or Depositories

Wachovia Bank
P O Box 563966
Charlotte, North Carolina 28262

Signed: Kevin Hagerty
Date Signed: 01/18/2012

(End FEC FORM 1)

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