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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-809929

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1. Corizon Health, Inc. Political Action Committee

    NOTE:Commmittee Name is different than previously reported

    105 Westpark Drive Suite 200
    Brentwood, TN 37027
    Email: corizonpac@electioncompliance.com

2. Date: 09/17/2012

3. FEC Committee ID #: C00345496 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

Corizon Health, Inc.
105 Westpark Drive
Suite 200
Brentwood, Tennessee 37027
Affiliated Relationship Code: Connected Organization

Custodian of Records:

PAC Outsourcing LLC
6192 Oxon Hill Rd
Suite 601
Oxon Hill, MD 20745
Title: Custodian of Records
Phone # (301) 839-6510

Treasurer:

Martin Moore
105 Westpark Drive
Suite 200
Brentwood, Tennessee 37027
Title: PAC Treasurer
Phone # (615) 376-1376

Designated Agent(s):

Banks or Depositories

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

Signed: Martin Moore
Date Signed: 09/17/2012

(End FEC FORM 1)

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