FEC Form 1 for BROOKE HOLDINGS INC AND JACKSON NATIONAL LIFE INSURANCE COMPANY SEPARATE SEGREGATED FUNDForm 1 for BROOKE HOLDINGS INC AND JACKSON NATIONAL LIFE INSURANCE COMPANY SEPARATE SEGREGATED FUND

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-111339

1. BROOKE HOLDINGS INC AND JACKSON NATIONAL LIFE INSURANCE COMPANY SEPARATE SEGREGATED FUND

1 Corporate Way
LANSING, MI 48951
Fax: 5177065517
Email: cindy.dolan@jnli.com

2. Date: 07/02/2003

3. FEC Committee ID #: C00254953 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Custodian of Records:

Cynthia Dolan
9741 Sunny Pointe Drive
Laingsburg, MI 48848
Title: PAC Administrator
Phone # (517) 367-4358

Treasurer:

Mr. Robert Fritts
2411 Sugar Tree
Lansing, Michigan 48917
Title: Vice President
Phone # (517) 702-2431

Designated Agent(s):

Banks or Depositories

Signed: Mr. Robert Fritts
Date Signed: 07/02/2003
Official Committee FAX: 5177065517

(End FEC FORM 1)

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