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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1167654

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1. Philips North America LLC Political Action Committee

    NOTE:Commmittee Name is different than previously reported

    1050 K Street, NW
    Suite 900
    Washington, DC 20001
    Email: PhilipsPAC@myfecnotices.com

2. Date: 06/26/2017

3. FEC Committee ID #: C00239780 This committee is a separate segregated fund. Its connected organization is a Corporation
     In addition, this committee is a Lobbyist/Registrant PAC.

Affiliated Committees/Organizations

Philips North America LLC
1050 K Street, NW
Suite 900
Washington, DC 20001
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Christine Fantacone
1050 K Street, NW
Suite 900
Washington, DC 20001
Title: Custodian of Records
Phone # (202) 403-8091

Treasurer:

Mayealie Adams
1050 K Street, NW
Suite 900
Washington, DC 20001
Title: Treasurer
Phone # (202) 403-8098

Designated Agent(s):

David Shoultz
1050 K Street, NW
Suite 900
Washington, DC 20001
Title: Assistant Treasurer
Phone # (202) 962-8556

Banks or Depositories

Wells Fargo
15th & H Financial Center
740 15th Street, NW
Washington, DC 20005

Signed: Mayealie Adams
Date Signed: 06/26/2017

(End FEC FORM 1)

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