FEC Form 1 for NCR CORPORATION POLITICAL ACTION COMMITTEE (NCRPAC)Form 1 for NCR CORPORATION POLITICAL ACTION COMMITTEE (NCRPAC)

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-847570

1. NCR CORPORATION POLITICAL ACTION COMMITTEE (NCRPAC)

20 F Street, N,W.
7th Floor
Washington, DC 20001

NOTE: Address is different than previously reported

Email: Elise.Kirban@ncr.com

2. Date: 01/17/2013

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
2651 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:

Tim Heffernan
20 F Street, NW
7th Floor
Washington, DC 20001
Title: Treasurer
Phone # (516) 810-0453

Designated Agent(s):

Patricia Toker
20 F Streeet, NW
7th Floor
Washington, DC 20001
Phone # (202) 507-6230

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-847570

1. NCR CORPORATION POLITICAL ACTION COMMITTEE (NCRPAC)

NOTE: Address is different than previously reported

2. Date: 01/17/2013

Affiliated Committees/Organizations

Custodian of Records:

Treasurer:

Designated Agent(s):

Banks or Depositories

Signed: Timothy M. Heffernan
Date Signed: 01/17/2013

(End FEC FORM 1)

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-847570

1. NCR CORPORATION POLITICAL ACTION COMMITTEE (NCRPAC)

NOTE: Address is different than previously reported

2. Date: 01/17/2013

Affiliated Committees/Organizations

Custodian of Records:

Treasurer:

Designated Agent(s):

Banks or Depositories

Signed: Timothy M. Heffernan Date Signed: 01/17/2013

(End FEC FORM 1)

Signed: Timothy M. Heffernan
Date Signed: 01/17/2013