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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1023482

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1. AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIAN PAC

    2831 Lone Oak Road
    Paducah, KY 42003
    Email: mmartin@asipp.org

    NOTE: Email address is different than previously reported

2. Date: 08/26/2015

3. FEC Committee ID #: C00351197 This committee is a Principal Campaign Committee. Candidate:
Party:
Office Sought:
State is in District:

Affiliated Committees/Organizations

NONE
, ____

Custodian of Records:

Treasurer:

Laxmaiah Manchikanti, MD
2075 Natchez Lane
Paducah, Kentucky 42001
Title: Treasurer
Phone # (270) 554-9412

Designated Agent(s):

Banks or Depositories

Bantera Bank
3151 Jackson Street
Paducah, Kentucky 42003

Signed: Laxmaiah Manchikanti, MD
Date Signed: 08/26/2015

(End FEC FORM 1)

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