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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1263400

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1. TIVITY HEALTH FEDERAL PAC

    701 COOL SPRINGS BLVD.
    FRANKLIN, TN 37067
    Email: Vicki.shepard@tivityhealth.com

2. Date: 09/18/2018

3. FEC Committee ID #: C00411918 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

Tivity Health
701 Cool Springs Blvd
Franklin, Tennessee 37067
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Derek Ferris
701 Cool Springs Blvd
Franklin, TN 37067
Title: Procurement Coord.
Phone # (615) 614-4249

Treasurer:

Adam Holland
701 Cool Springs Blvd
Franklin, Tennessee 37067
Title: CFO
Phone # (800) 869-5311

Designated Agent(s):

Derek Ferris
701 Cool Springs Blvd
Franklin, Tennessee 37067
Title: Procurement Coord.
Phone # (615) 614-4249

Banks or Depositories

SunTrust Bank
PO Box 622227
Orlando, Florida 32862

Signed: Adam Holland
Date Signed: 09/18/2018
Official Committee URL: www.tivityhealth.com

(End FEC FORM 1)

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