FEC Form 1 for American Medical Security Group Inc. PACForm 1 for American Medical Security Group Inc. PAC

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-156011

1. American Medical Security Group Inc. PAC

NOTE:Commmittee Name is different than previously reported

3100 AMS Boulevard
P.O. Box 19032
Green Bay, WI 543079032
Fax: 9206619746
Email: www.amsinfo@eAMS.com

2. Date: 12/06/2004

3. FEC Committee ID #: C00283457 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

American Medical Security Group Inc.
3100 AMS Boulevard
PO Box 19032
Green Bay, Wisconsin 543079032
Relationship: Connected Organizati
Organization Type: Corporation

Custodian of Records:

Timothy Moore
1821 South Sunkist Circle
De Pere, WI 54115
Title: President
Phone # (920) 661-3075

Treasurer:

James Prochnow
1090 Coprinus Court
Green Bay, Wisconsin 54313
Title: Treasurer
Phone # (920) 661-2038

Designated Agent(s):

Timothy Moore
1821 South Sunkist Circle
De Pere, Wisconsin 54115
Title: President
Phone # (920) 661-3075

James Prochnow
1090 Coprinus Court
Green Bay, Wisconsin 54313
Title: Treasurer
Phone # (920) 661-2038

William May
2582 Misty River Lane
De Pere, Wisconsin 54115
Title: VP & Secretary
Phone # (920) 661-2751

Patrick O'Connell
167 Brule Road
DePere, Wisconsin 54115
Title: Assistant Treasurer
Phone # (920) 661-2749

Cheryl Thomson
222 Forest Drive
Sobieski, Wisconsin 54171
Title: Assistant Secretary
Phone # (920) 661-3078

Banks or Depositories

Bank One - Green Bay
P.O. Box 19029
Green Bay, Wisconsin 54307

Signed: James Prochnow
Date Signed: 12/06/2004
Official Committee URL: www.eAMS.com
Official Committee FAX: 9206619746

(End FEC FORM 1)

Generated Wed Jul 17 17:37:16 2024