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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1071657

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1. NCR CORPORATION POLITICAL ACTION COMMITTEE (NCRPAC)

    20 F Street, N.W.
    7th Floor
    Washington, DC 20001
    Email: patricia.toker@ncr.com

2. Date: 05/11/2016

3. FEC Committee ID #: C00324103 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

Committee ID# C00324103
NCR Corporation
3097 Satellite Blvd
Duluth, Georgia 30096
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Patricia Toker
20 F Street, NW
7th Floor
Washington, DC 20001
Title: PAC Manager
Phone # (202) 507-6230

Treasurer:

Justin W. Clay
3097 Satellite Blvd.
Duluth, Georgia 30096
Title: Treasurer
Phone # (770) 689-2286

Designated Agent(s):

Patricia Toker
20 F Street, NW
7th Floor
Washington, DC 20001
Title: PAC Manager
Phone # (202) 507-6230

Banks or Depositories

JPMorgan Chase
100 East Broad Street Floor 11
Columbus, Ohio 43215

Signed: Justin W. Clay
Date Signed: 05/11/2016

(End FEC FORM 1)

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