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-1058476

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

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

NOTE: Email address is different than previously reported

2. Date: 10/18/2010

3. FEC Committee ID #: C00412247 This committee is a separate segregated fund. Its connected organization is a Corporation W/O Capital Stock
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:

Mr Robert Post
55 Water Street
New york, NY 10041
Phone # (646) 447-6911

Treasurer:

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

Designated Agent(s):

Banks or Depositories

TD Bank
2 Wall St.
New York, New York 10005

Signed: Ms. Robin Chappelle Golston
Date Signed: 04/06/2016

(End FEC FORM 1)

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