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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-834699

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1. American Society of Plastic Surgeons PLASTYPAC

    20 F Street NW
    #310A
    Washington, DC 20001
    Email: lshoaf@plasticsurgery.org

2. Date: 11/27/2012

3. FEC Committee ID #: C00249342 This committee is a separate segregated fund. Its connected organization is a Trade Association
     In addition, this committee is a Lobbyist/Registrant PAC.

Affiliated Committees/Organizations

American Society of Plastic Surgeons
444 E. Algonquin
Arlington Heights, Illinois 60005
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Lori Shoaf, J.D.
1640 Wisconsin Ave NW
Washington, DC 20007
Title: Custodian of Records
Phone # (202) 672-1518

Treasurer:

Mr. David Song, MD
5841 South Maryland Avenue
Chicago, Illinois 60637
Title: Treasurer
Phone # (202) 672-1518

Designated Agent(s):

Mr. William Seward
1640 Wisconsin Ave NW
Washington, DC 20007
Title: Treasurer
Phone # (202) 672-1518

Mr. David Song, MD
5841 South Maryland Avenue
Chicago, Illinois 60637
Title: Treasurer
Phone # (202) 672-1518

Banks or Depositories

JP Morgan Chase
1201 South Milwaukee Ave
Libertyville, Illinois 60048

Signed: Mr. David Song, MD
Date Signed: 11/27/2012

(End FEC FORM 1)

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