FEC Form 1 for Blue Cross and Blue Shield of Kansas, Inc. Employee PACForm 1 for Blue Cross and Blue Shield of Kansas, Inc. Employee PAC

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-415742

1. Blue Cross and Blue Shield of Kansas, Inc. Employee PAC

NOTE:Commmittee Name is different than previously reported

1133 SW Topeka Blvd.
CC:855 - B3
Topeka, KS 66629
Email: ann.shelton@bcbsks.com

2. Date: 04/30/2009

3. FEC Committee ID #: C00197202 This committee is a separate segregated fund. Its connected organization is a Corporation W/O Capital Stock
In addition, this committee is a Lobbyist/Registrant PAC.

Affiliated Committees/Organizations

Blue Cross and Blue Shield of Kansas, Inc.
1133 SW Topeka Blvd.
Topeka, Kansas 66629
Affiliated Relationship Code: Connected Organization

Committee ID# C00194746
BLUEPAC - BLUE CROSS BLUE SHIELD ASSOC
1310 G STREET NW
WASHINGTON, DC 20005
Affiliated Relationship Code: Affiliated Committee

Custodian of Records:

Treasurer:

Ann M. Shelton
1133 SW Topeka Blvd
Topeka, Kansas 66629
Title: Treasurer
Phone # (785) 291-8262

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-415742

1. Blue Cross and Blue Shield of Kansas, Inc. Employee PAC

NOTE:Commmittee Name is different than previously reported

2. Date: 04/30/2009

Affiliated Committees/Organizations

Custodian of Records:

Treasurer:

Designated Agent(s):

Banks or Depositories

Signed: Ann M. Shelton
Date Signed: 04/30/2009

(End FEC FORM 1)

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-415742

1. Blue Cross and Blue Shield of Kansas, Inc. Employee PAC

NOTE:Commmittee Name is different than previously reported

2. Date: 04/30/2009

Affiliated Committees/Organizations

Custodian of Records:

Treasurer:

Designated Agent(s):

Banks or Depositories

Signed: Ann M. Shelton Date Signed: 04/30/2009

(End FEC FORM 1)

Signed: Ann M. Shelton
Date Signed: 04/30/2009