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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1700678

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1. KAH Hospice Company, Inc. PAC

    3350 Riverwood Parkway, Suite 1400
    Atlanta, GA 30339
    Email: GentivaPAC@myfecnotices.com

2. Date: 04/13/2023

3. FEC Committee ID #: C00407080 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

KAH Hospice Company, Inc.
3350 Riverwood Parkway, Suite 1400
Atlanta, Georgia 30339
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Ronald Lazas, Jr.
3350 Riverwood Pkwy, Suite 1400
Atlanta, GA 30339
Title: PAC Treasurer
Phone # (770) 951-6426

Treasurer:

Ronald Lazas, Jr.
3350 Riverwood Pkwy, Suite 1400
Atlanta, Georgia 30339
Title: PAC Treasurer
Phone # (770) 951-6426

Designated Agent(s):

Banks or Depositories

Bank of America
PO Box 31900
Tampa, Florida 336313900

Signed: Ronald Lazas, Jr.
Date Signed: 04/17/2023

(End FEC FORM 1)

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