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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-885122

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1. ACADIAN AMBULANCE SERVICE, INC. EMPLOYEE PAC

    P.O. BOX 98000
    LAFAYETTE, LA 70509
    Email: tburke@acadian.com

2. Date: 08/15/2013

3. FEC Committee ID #: C00335570 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

Acadian Ambulance Service Inc
PO Box 98000
Lafayette, Louisiana 70509
Affiliated Relationship Code: Connected Organization

Custodian of Records:

TIMOTHY BURKE
109 Fountain View Dr
Youngsville, LA 70592
Title: VP of Finance
Phone # (337) 291-3361

Treasurer:

TIMOTHY BURKE
109 Fountain View Dr
Youngsville, Louisiana 70592
Title: VP of Finance
Phone # (337) 291-3361

Designated Agent(s):

Banks or Depositories

JP Morgan Chase Bank
PO Box 260180
Baton Rouge, Louisiana 70826

Signed: TIMOTHY BURKE
Date Signed: 08/15/2013
Official Committee URL: http://www.acadian.com

(End FEC FORM 1)

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