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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-54316

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1. GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY POLITICAL ACTION COMMITTEE

    8525 E ORCHARD ROAD
    2T3
    Greenwood Village, CO 80111
    Email: wendy.cloe@gwl.com

2. Date: 10/15/2002

3. FEC Committee ID #: C00263723 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Custodian of Records:

Treasurer:

Mark Pavlik
8515 E. Orchard Road 7T2
Greenwood Village, Colorado 80111
Title: Treasurer
Phone # (303) 737-4144

Designated Agent(s):

Banks or Depositories

Signed: Mark Pavlik
Date Signed: 10/15/2002

(End FEC FORM 1)

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