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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-733132

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1. MO - Political Action Committee of the Missouri Hospital Association

    PO Box 60
    4712 Country Club Drive
    Jefferson City, MO 651020060
    Email: dlandon@mail.mhanet.com

2. Date: 07/05/2011

3. FEC Committee ID #: C00289777 This committee is a separate segregated fund. Its connected organization is a Trade Association
     In addition, this committee is a Lobbyist/Registrant PAC.

Affiliated Committees/Organizations

Missouri Hospital Association
P.O. Box 60
4712 Country Club Drive
Jefferson City, Missouri 651020060
Affiliated Relationship Code: Connected Organization

American Hospital Association Politica
325 Seventh Street, NW
Washington, DC 20004
Affiliated Relationship Code: Affiliated Committee

Custodian of Records:

Kathleen C. Poff
P.O. Box 60
Jefferson City, MO 651020060
Title: Assistant Treasurer
Phone # (573) 893-3700

Treasurer:

Daniel Landon
PO Box 60
4712 Country Club Drive
Jefferson City, Missouri 651020060
Title: Treasurer
Phone # (573) 893-3700

Designated Agent(s):

Kathleen Poff
P.O. Box 60
4712 Country Club Drive
Jefferson City, Missouri 651020060
Title: Assistant Treasurer
Phone # (573) 893-3700

Herb Kuhn
P.O. Box 60
4712 Country Club Drive
Jefferson City, Missouri 651020060
Title: Agent
Phone # (573) 893-3700

Mary Becker
P.O. Box 60
4712 Country Club Drive
Jefferson City, Missouri 651020060
Title: Agent
Phone # (573) 893-3700

Banks or Depositories

Central Bank
238 Madison Street
Jefferson City, Missouri 65101

Signed: Daniel Landon
Date Signed: 07/05/2011

FORM TEXT

(End FEC FORM 1)

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