FEC Form 1 for PacifiCare Health Systems Inc. Employees' Political Action CommitteeForm 1 for PacifiCare Health Systems Inc. Employees' Political Action Committee

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-103698

1. PacifiCare Health Systems Inc. Employees' Political Action Committee

NOTE:Commmittee Name is different than previously reported

M/S CY20-536
5995 Plaza Drive
Cypress, CA 90630
Fax: 714-226-3653
Email: leigh.volkland@phs.com

2. Date: 01/15/2004

3. FEC Committee ID #: C00240903 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

PacifiCare Health Systems Inc.
5995 Plaza Drive CY20-536
Cypress, California 90630
Relationship: Connected organization
Organization Type: Corporation

Custodian of Records:

Phone # 0

Treasurer:

Nick Franklin
M/S CY20-536
5995 Plaza Drive
Cypress, California 90630
Title: SVP Public Affairs
Phone # (714) 226-3360

Designated Agent(s):

Leigh Volkland
5995 Plaza Drive CY20-536
Cypress, California 90630
Title: Director
Phone # (714) 226-3211

Banks or Depositories

Wells Fargo
707 Wilshire Boulevard
Los Angeles, California 90017

Signed: Nick Franklin
Date Signed: 01/15/2004
Official Committee FAX: 714-226-3653

FORM TEXT

(End FEC FORM 1)

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