FEC Form 1 for Prison Health Services Inc. Political Action CommitteeForm 1 for Prison Health Services Inc. Political Action Committee

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-213726

1. Prison Health Services Inc. Political Action Committee

105 Westpark Drive Suite 200
Brentwood, TN 37027

2. Date: 04/10/2006

3. FEC Committee ID #: C00345496 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Prison Health Services Inc.
105 Westpark Drive
Suite 200
Brentwood, Tennessee 37027
Relationship: Connected Organization
Organization Type: Corporation

Custodian of Records:

PAC Services LLC
7700 Old Branch Avenue
Suite D-103
Clinton, MD 20735
Title: Custodian of Records
Phone # (301) 868-1888

Treasurer:

Thomas West
105 Westpark Drive
Suite 200
Brentwood, Tennessee 37027
Title: PAC Treasurer
Phone # (615) 376-0655

Designated Agent(s):

Banks or Depositories

Bank of America
One Bank of America Plaza
Nashville, Tennessee 372391697

Signed: Thomas West
Date Signed: 04/10/2006

(End FEC FORM 1)

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