FEC Form 1 for GHC ANCILLARY CORPORATION POLITICAL ACTION COMMITTEEForm 1 for GHC ANCILLARY CORPORATION POLITICAL ACTION COMMITTEE

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-745165

1. GHC ANCILLARY CORPORATION POLITICAL ACTION COMMITTEE

NOTE:Commmittee Name is different than previously reported

101 EAST STATE STREET
KENNETT SQUARE, PA 19348
Email: Laurence.Lane@genesishcc.com

2. Date: 07/25/2011

3. FEC Committee ID #: C00292094 This committee is a separate segregated fund. Its connected organization is a Corporation
In addition, this committee is a Lobbyist/Registrant PAC.

Affiliated Committees/Organizations

GHC Ancillary Corporation
101 E. State Street
Kennett Square, Pennsylvania 19348
Affiliated Relationship Code: Connected Organization

Custodian of Records:

LAURENCE F LANE
1616 STEPHENS DRIVE
WAYNE, PA 19087

Treasurer:

LAURENCE F LANE
1616 STEPHENS DRIVE
WAYNE, Pennsylvania 19087

Designated Agent(s):

Banks or Depositories

Wells Fargo Bank
400 Scarlett Road
Kennett Square, Pennsylvania 19348

Signed: LAURENCE F LANE
Date Signed: 09/19/2011

(End FEC FORM 1)

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