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-714680

1. UNITED SURGICAL PARTNERS INTERNATIONAL, INC. POLITICAL ACTION COMMITTEE

15305 Dallas Parkway, Suite 1600
Addison, TX 75001
Email: tmartin@uspi.com

NOTE: Email address is different than previously reported

2. Date: 02/16/2011

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.
15305 Dallas Parkway
Suite 1600
Addison, Texas 750016491
Affiliated Relationship Code: Connected Organization

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

Custodian of Records:

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

Treasurer:

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

Designated Agent(s):

Alison T. Edwards
411 W. 7th Street
Suite 306
Fort Worth, Texas 76102
Title: Assistant Treasurer
Phone # (817) 771-0041

Banks or Depositories

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

Signed: J. Anthony Martin
Date Signed: 02/16/2011

(End FEC FORM 1)

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