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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1237892

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1. EMBLEMHEALTH SERVICES COMPANY LLC FEDERAL PAC (AKA EMBLEMHEALTH PAC)

    55 WATER STREET
    NEW YORK, NY 10041
    Email: cberkowitz@emblemhealth.com;IHendrickson@emblemhealth.com

    NOTE: Email address is different than previously reported

2. Date: 06/14/2018

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

EmblemHealth Services Company LLC
55 Water Street
New York, New York 10041
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Ms. Cara Berkowitz
55 water Street
New York, NY 100418190
Title: VP Gov't Aff Policy
Phone # (646) 447-7399

Treasurer:

Ms. Cara Berkowitz
55 water Street
New York, New York 100418190
Title: VP Gov't Aff Policy
Phone # (646) 447-7399

Designated Agent(s):

Ms Cara Berkowitz
55 water Street
New York, New York 100418190
Title: VP Gov't Aff Policy
Phone # (646) 447-7399

Banks or Depositories

TD Bank
2 Wall Street
New York, New York 10005

Signed: Ms. Cara Berkowitz
Date Signed: 06/14/2018

(End FEC FORM 1)

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