FEC Form 1 for United Surgical Partners International, Inc. Political Action CommitteeForm 1 for United Surgical Partners International, Inc. Political Action Committee

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-451843

1. United Surgical Partners International, Inc. Political Action Committee

15305 Dallas Parkway, Suite 1600
Addison, TX 75001
Email: jcagle@unitedsurgical.com

2. Date: 02/09/2010

3. FEC Committee ID #: C00402073 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

United Surgical Partners International Inc. PAC (Texas)
15305 Dallas Parkway, Suite 1600
Addison, Texas 75001
Affiliated Relationship Code: Affiliated Committee

United Surgical Partners International
15305 Dallas Parkway, Suite 1600
Addison, Texas 75001
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Jason Cagle
15305 Dallas Parkway, Suite 1600
Addison, TX 750016491
Title: Custodian of Records
Phone # (972) 713-3568

Treasurer:

J. Anthony Martin
15305 Dallas Parkway, Suite 1600
Addison, Texas 750016491
Title: Treasurer
Phone # (972) 713-3510

Designated Agent(s):

Mark Kopser
15305 Dallas Parkway
Suite 1600
Addison, Texas 750016491
Title: Designated Agent
Phone # (972) 713-3503

Banks or Depositories

Bank of America
Bank of America, N.A.
Dallas, Texas 752832406

Signed: J. Anthony Martin
Date Signed: 02/09/2010

FORM TEXT

(End FEC FORM 1)

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