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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1519913

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1. Envision Healthcare Corporation Political Action Committee

    1A Burton Hills Blvd.
    Nashville, TN 37215
    Email: fecinfo@pass1.com;patrick.velliky@envisionhealth.com

    NOTE: Email address is different than previously reported

2. Date: 06/15/2021

3. FEC Committee ID #: C00398271 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

Envision Healthcare Corporation
1A Burton Hills Boulevard
Nashville, Tennessee 37215
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Patrick Velliky
1A Burton Hills Blvd
Nashville, TN 37215
Title: Treasurer
Phone # (202) 412-3407

Treasurer:

Patrick Velliky
1A Burton Hills Blvd
Nashville, Tennessee 37215
Title: Treasurer
Phone # (202) 412-3407

Designated Agent(s):

Banks or Depositories

Wells Fargo Bank
600 Cuthbert Blvd
Haddon Township, New Jersey 08108

Signed: Patrick Velliky
Date Signed: 06/15/2021

FORM TEXT-1

(End FEC FORM 1)

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