FEC Form 1 for AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIAN PACForm 1 for AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIAN PAC

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-204148

1. AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIAN PAC

2831 Lone Oak Road
Paducah, KY 42003
Email: drm@thepainmd.com

2. Date: 02/24/2006

3. FEC Committee ID #: C00351197 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Society of Interventional Pain Management Surgery Centers PAC
2831 Lone Oak Road
Paducah, Kentucky 42003
Relationship: Affiliated
Organization Type: Corporation

Custodian of Records:

Treasurer:

Laxmaiah Manchikanti
2075 Natchez Lane
Paducah, Kentucky 42001
Title: President
Phone # (270) 554-8373

Designated Agent(s):

Dr. Jose J. Rivera
450 Ash Creek
Paducah, Kentucky 42001

Banks or Depositories

Bantera Bank
3151 Jackson Street
Paducah, Kentucky 42003

Signed: Laxmaiah Manchikanti
Date Signed: 02/24/2006

(End FEC FORM 1)

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