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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-788823

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1. Nestle Waters North America Inc. PAC

    900 Long Ridge Rd. Building 2
    Stamford, CT 069021138
    Email: cheryl.riccio@waters.nestle.com

    NOTE: Email address is different than previously reported

2. Date: 06/05/2012

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 069021138
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:

Cheryl Riccio
900 Long Ridge Rd. Building 2
Stamford, CT 06902
Title: Custodian of Records
Phone # (203) 276-5854

Treasurer:

Cheryl Riccio
900 Long Ridge Rd. Building 2
Stamford, Connecticut 06902
Title: Treasurer
Phone # (203) 276-5854

Designated Agent(s):

Scott Bucci
900 Long Ridge Rd. Building 2
Stamford, Connecticut 06902
Title: Assistant Treasurer
Phone # (203) 863-0361

Banks or Depositories

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

Signed: Cheryl Riccio
Date Signed: 06/05/2012

FORM TEXT

(End FEC FORM 1)

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