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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1216173

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1. Capital BluePAC, The Political Action Committee of Capital BlueCross

    P.O. Box 60710
    Harrisburg, PA 171060710
    Email: Brittany.Rieker@CapBlueCross.com;outsourcing@aristotle.com

    NOTE: Email address is different than previously reported

2. Date: 04/01/2018

3. FEC Committee ID #: C00270967 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

Committee ID# C00194746
BluePAC, The BlueCross and BlueShield Association Political Action Committee
c/o Mr. Berry Trimble BCBSA
1310 G Street, NW
Washington, DC 200053000
Affiliated Relationship Code: Affiliated Committee

Capital BlueCross
2500 Elmerton Ave
Harrisburg, Pennsylvania 171779764
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Brittany Rieker
PO Box 60710
Harrisburg, PA 171060710
Title: Custodian of Records
Phone # (717) 541-6135

Treasurer:

Douglas Furness
P.O. Box 60710
Harrisburg, Pennsylvania 171060710
Title: Treasurer
Phone # (717) 541-6135

Designated Agent(s):

Banks or Depositories

M&T Bank
1002 North 7th Street
Harrisburg, Pennsylvania 17102

Signed: Douglas Furness
Date Signed: 03/22/2018

FORM TEXT-1

(End FEC FORM 1)

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