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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-703628

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1. The Nestle Waters North America Inc. Political Action Committee

    900 Long Ridge Rd. Building 2
    Stamford, CT 069021138

    NOTE: Address is different than previously reported

    Email: kevin.kolanda@waters.nestle.com

    NOTE: Email address is different than previously reported

2. Date: 12/30/2010

3. FEC Committee ID #: C00302943 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

Nestle Waters North America Inc.
900 Long Ridge Rd. Building 2
Stamford, Connecticut 06902
Affiliated Relationship Code: Connected Organization

Committee ID# C00382119
Nestle Purina PetCare Co PAC
Checkboard Square
St. Louis, Missouri 63164
Affiliated Relationship Code: Affiliated Committee

Custodian of Records:

Kevin Kolanda
900 Long Ridge Rd. Building 2
Stamford, CT 06902
Title: Custodian
Phone # (203) 276-5852

Treasurer:

Kevin Kolanda
900 Long Ridge Rd. Building 2
Stamford, Connecticut 06902
Title: Treasurer
Phone # (203) 276-5852

Designated Agent(s):

Robert Schaab
900 Long Ridge Rd. Building 2
Stamford, Connecticut 06902
Title: Assistant Treasurer
Phone # (203) 629-7232

Banks or Depositories

Bank of America
433 Boston Post Rd.
Port Chester, New York 10573

Signed: Kevin Kolanda
Date Signed: 12/30/2010

FORM TEXT

(End FEC FORM 1)

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