FEC Form 1 for BLUEPAC OF PENNSYLVANIAForm 1 for BLUEPAC OF PENNSYLVANIA

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-150045

1. BLUEPAC OF PENNSYLVANIA

NOTE:Commmittee Name is different than previously reported

P. O. Box 60710
Harrisburg, PA 171060710
Fax: 7175263207
Email: linda.melusky@capbluecross.com

2. Date: 10/27/2004

3. FEC Committee ID #: C00270967 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Independence Blue Cross
1901 Market Street
Philadelphia, Pennsylvania 19103
Relationship: Affiliated Corp.
Organization Type: Corporation

BlueCross and BlueShield Association
1310 G Street NW
Washington, DC 20005
Relationship: Affiliated Committee
Organization Type: Membership Organization

Custodian of Records:

Ms Traci Lumadue
2500 Elmerton Avenue
Harrisburg, PA 171773238
Title: Jr. Accountant
Phone # (717) 541-7257

Treasurer:

Mr. Aji Abraham
2500 Elmerton Avenue
Harrisburg, Pennsylvania 171772531
Title: Director/Treasurer
Phone # (717) 541-6134

Designated Agent(s):

Ms Linda Melusky
2500 Elmerton Avenue
Harrisburg, Pennsylvania 171772531
Title: Asst. Treasurer
Phone # (717) 541-6135

Ms Traci Lumadue
2500 Elmerton Avenue
Harrisburg, Pennsylvania 171773238

Banks or Depositories

M&T Bank
213 Market Street
Harrisburg, Pennsylvania 17101

Signed: Mr. Aji Abraham
Date Signed: 11/01/2004
Official Committee URL: www.capbluecross.com
Official Committee FAX: 7175263207

(End FEC FORM 1)

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