FEC Form 1 for AVIVA USA POLITICAL ACTION COMMITTEEForm 1 for AVIVA USA POLITICAL ACTION COMMITTEE

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-395197

1. AVIVA USA POLITICAL ACTION COMMITTEE

699 Walnut Street
Suite 2000
DES MOINES, IA 50309
Fax: 5155572412
Email: linda.olson@avivausa.com

2. Date: 01/13/2009

3. FEC Committee ID #: C00180901 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

Committee ID# C00180901
AVIVA USA POLITICAL ACTION COMMITTEE
699 Walnut Street
Suite 2000
DES MOINES, Iowa 50309
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Michael H. Miller
699 Walnut Street, Suite 2000
Des Moines, IA 50309
Title: Treasurer
Phone # (515) 362-3657

Treasurer:

Michael H. Miller
699 Walnut Street, Suite 2000
Des Moines, Iowa 50309
Title: Treasurer
Phone # (515) 362-3657

Designated Agent(s):

Michael H. Miller
699 Walnut Street, Suite 2000
Des Moines, Iowa 50309
Title: Treasurer
Phone # (515) 362-3657

Banks or Depositories

Bankers Trust Company
665 Locust Street
Des Moines, Iowa 50309

Signed: Michael H. Miller
Date Signed: 01/13/2009
Official Committee FAX: 5155572412

(End FEC FORM 1)

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