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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1263830

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1. Jackson Holdings LLC and Jackson National Life Insurance Company Separate Segregated Fund (Jackson National PAC)

    1 Corporate Way
    Lansing, MI 48951
    Email: martha.vozza@jackson.com

    NOTE: Email address is different than previously reported

2. Date: 09/24/2018

3. FEC Committee ID #: C00254953 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

Jackson Holdings LLC and Jackson National Life Insurance Company
1 Corporate Way
Lansing, Michigan 48951
Affiliated Relationship Code: Connected Organization

Committee ID# C00686055
Jackson Holdings LLC and Jackson Natio
1 Corporate Way
Lansing, Michigan 48951
Affiliated Relationship Code: Affiliated Committee

Custodian of Records:

Martha Vozza
1 Corporate Way
Lansing, MI 48951
Title: Asst. Treasurer
Phone # (517) 367-4055

Treasurer:

Michael Costello
1 Corporate Way
Lansing, Michigan 48951
Title: Treasurer
Phone # (517) 367-3854

Designated Agent(s):

Martha Vozza
1 Corporate Way
Lansing, Michigan 48951
Title: Asst. Treasurer
Phone # (517) 367-4055

Banks or Depositories

JP Morgan Chase
6015 S. Pennsylvania
Lansing, Michigan 48911

Signed: Martha Vozza (Asst. Treasurer)
Date Signed: 09/24/2018

FORM TEXT-1

(End FEC FORM 1)

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