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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-822517

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1. OHIO AMBULATORY SURGERY CENTERS PAC

    P.O. Box 340225
    COLUMBUS, OH 432340225
    Email: rleffler@oaasc.net

2. Date: 10/19/2012

3. FEC Committee ID #: C00389866 This committee is a separate segregated fund. Its connected organization is a Trade Association

Affiliated Committees/Organizations

Ohio Association of Ambulatory Surgery Centers
P.O. Box 340225
Columbus, Ohio 43234
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Randy Leffler
P.O. Box 340225
Columbus, OH 43234
Title: Executive Director
Phone # (614) 358-0177

Treasurer:

Randy Leffler
P.O. Box 340225
Columbus, Ohio 43234
Title: Treasurer
Phone # (614) 358-0177

Designated Agent(s):

Banks or Depositories

Huntington National Bank
PO Box 1558 EA1W37
Columbus, Ohio 43216

Signed: Randy Leffler
Date Signed: 10/19/2012

(End FEC FORM 1)

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