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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1126413

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1. PERFORMANT FINANCIAL CORPORATION POLITICAL ACTION COMMITTEE

    2350 KERNER BLVD., SUITE 250
    SAN RAFAEL, CA 94901
    Email: fecform1@nmgovlaw.com

2. Date: 11/16/2016

3. FEC Committee ID #: C00411199 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

PERFORMANT FINANCIAL CORPORATION
333 N CANYONS PARKWAY, SUITE 100
LIVERMORE, California 94551
Affiliated Relationship Code: Connected Organization

Custodian of Records:

CHRISTOPHER E. SKINNELL
2350 KERNER BLVD., SUITE 250
SAN RAFAEL, CA 949041
Title: Custodian of Records
Phone # (415) 389-6800

Treasurer:

CHRISTOPHER E. SKINNELL
2350 KERNER BLVD., SUITE 250
SAN RAFAEL, California 94901
Title: Treasurer
Phone # (415) 389-6800

Designated Agent(s):

JAMES W. CARSON
2350 KERNER BLVD., SUITE 250
SAN RAFAEL, California 94901
Title: Assistant Treasurer
Phone # (415) 389-6800

Banks or Depositories

BANK OF MARIN
504 TAMALPAIS DRIVE
CORTE MADERA, California 94925

Signed: CHRISTOPHER E. SKINNELL
Date Signed: 11/16/2016

(End FEC FORM 1)

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