FEC Form 1 for EmblemHealth Services Company LLC Federal PAC (aka EmblemHealth PAC)Form 1 for EmblemHealth Services Company LLC Federal PAC (aka EmblemHealth PAC)

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1032175

1. EmblemHealth Services Company LLC Federal PAC (aka EmblemHealth PAC)

55 WATER STREET
NEW YORK, NY 10041
Email: emblemfedpac@emblemhealth.com

2. Date: 10/18/2010

3. FEC Committee ID #: C00412247 This committee is a separate segregated fund. Its connected organization is a
In addition, this committee is a Lobbyist/Registrant PAC.

Affiliated Committees/Organizations

Health Insurance Plan of Greater New York
55 Water St.
New York, New York 10041
Affiliated Relationship Code: Connected Organization

Custodian of Records:

David Abernethy
55 Water St.
5th Floor
New York, NY 10041
Title: Senior VP
Phone # (646) 447-6001

Treasurer:

Ms. Robin Chappelle Golston
55 Water Street
New York, New York 10041
Title: VP
Phone # (646) 447-4516

Designated Agent(s):

Jay A. Schoenfeld
55 Water St.
New York, New York 10041
Title: Assistant Treasurer
Phone # (646) 447-5950

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1032175

1. EmblemHealth Services Company LLC Federal PAC (aka EmblemHealth PAC)

2. Date: 10/18/2010

Affiliated Committees/Organizations

Custodian of Records:

Treasurer:

Designated Agent(s):

Banks or Depositories

Signed: Ms. Robin Chappelle Golston
Date Signed: 11/10/2015

(End FEC FORM 1)

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1032175

1. EmblemHealth Services Company LLC Federal PAC (aka EmblemHealth PAC)

2. Date: 10/18/2010

Affiliated Committees/Organizations

Custodian of Records:

Treasurer:

Designated Agent(s):

Banks or Depositories

Signed: Ms. Robin Chappelle Golston Date Signed: 11/10/2015

(End FEC FORM 1)

Signed: Ms. Robin Chappelle Golston
Date Signed: 11/10/2015