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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-994214

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1. Corizon Health, Inc. Political Action Committee

    103 Powell Court
    Brentwood, TN 37027
    Email: corizonpac@electioncompliance.com

2. Date: 02/19/2015

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

Affiliated Committees/Organizations

Corizon Health, Inc.
103 Powell Court
Brentwood, Tennessee 37027
Affiliated Relationship Code: Connected Organization

Custodian of Records:

PAC Outsourcing LLC
5845 Richmond Highway
Suite 820
Alexandria, VA 22303
Title: Custodian of Records
Phone # (703) 347-6551

Treasurer:

Jeff Sholey
103 Powell Court
Brentwood, Tennessee 37027
Title: PAC Treasurer
Phone # (615) 373-3100

Designated Agent(s):

Banks or Depositories

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

Signed: Jeff Sholey
Date Signed: 02/19/2015

(End FEC FORM 1)

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