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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-182718

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1. AMERICAN PREVENTIVE MEDICAL ASSOCIATION PAC

    P.O. Box 458
    PO BOX 458
    Great Falls, VA 22066

2. Date: 07/28/2005

3. FEC Committee ID #: C00293902 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Custodian of Records:

Treasurer:

Brenna Hill
P.O. Box 458
Great Falls, Virginia 22066
Title: Treasurer
Phone # (703) 759-0662

Designated Agent(s):

Banks or Depositories

Signed: Brenna Hill
Date Signed: 07/28/2005

(End FEC FORM 1)

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