FEC Form 1 for Tyco International (US) Inc. Employees Political Action CommitteeForm 1 for Tyco International (US) Inc. Employees Political Action Committee

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-130651

1. Tyco International (US) Inc. Employees Political Action Committee

9 Roszel Road
Princeton, NJ 08540
Email: sbunning@tyco.com

2. Date: 08/10/2004

3. FEC Committee ID #: C00113753 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Tyco International (US) Inc.
9 Roszel Road
Princeton, New Jersey 08540
Relationship: Connected
Organization Type: Corporation

Custodian of Records:

Ms Cresta Heltemes
Political Action Committee Service
7700 Old Branch Avenue # D-103
Clinton, MD 20735
Title: Custodian of Records
Phone # (301) 868-1888

Treasurer:

Mr. C.A. (John) Davidson
9 Roszel Road
Princeton, New Jersey 08540
Title: Treasurer
Phone # (609) 720-4200

Designated Agent(s):

Kathy Cahill
9 Roszel Road
Princeton, New Jersey 08540
Title: Assistant Treasurer
Phone # (609) 720-4200

Banks or Depositories

Signed: Mr. C.A. (John) Davidson
Date Signed: 08/10/2004

(End FEC FORM 1)

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