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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-503686

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

    NOTE:Commmittee Name is different than previously reported

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

Arthur J. Byrd
55 Water St.
13th Floor
New York, New York 10041
Title: Vice President
Phone # (646) 447-6263

Designated Agent(s):

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

Banks or Depositories

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

Signed: Jay A. Schoenfeld
Date Signed: 10/18/2010

(End FEC FORM 1)

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