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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-473490

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1. Wake Emergency Physicians, PA PAC

    570 New Waverly Place
    Suite 210
    Cary, NC 27518
    Email: brohawn@weppa.org

2. Date: 06/03/2010

3. FEC Committee ID #: C00412841 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

Wake Emergency Physicians, PA
570 New Waverly Place
Suite 210
Cary, North Carolina 27518
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Daniel Adam Staniszewski
570 New Waverly Place
Suite 210
Cary, NC 27518
Title: Director of Acctg
Phone # (919) 859-3373

Treasurer:

Michael Talmadge Brohawn
570 New Waverly Place
Suite 210
Cary, North Carolina 27518
Title: Administrator
Phone # (919) 859-3373

Designated Agent(s):

Banks or Depositories

BB&T
434 Fayetteville Street
Raleigh, North Carolina 27601

Signed: Michael Talmadge Brohawn
Date Signed: 06/03/2010

(End FEC FORM 1)

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