FEC Form 1 for Society of Interventional Pain Management Surgery Centers PACForm 1 for Society of Interventional Pain Management Surgery Centers PAC

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-204155

1. Society of Interventional Pain Management Surgery Centers PAC

2831 Lone Oak Road
Paducah, KY 42003
Email: drm@thepainmd.com

2. Date: 02/24/2006

3. FEC Committee ID #: C00416628 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Committee ID# C00351197
American Society of Interventional Pain Physicians PAC
2831 Lone Oak Road
Paducah, Kentucky 42003
Relationship: Affiliated
Organization Type: Membership Organization

Custodian of Records:

Treasurer:

Laxmaiah Manchikanti, MD
2831 Lone Oak Road
Paducah, Kentucky 42003

Designated Agent(s):

Jose Rivera, MD
2831 Lone Oak Rd
Paducah, Kentucky 42003
Title: Assistant Treasurer
Phone # (270) 554-8373

Banks or Depositories

Banterra Bank
3151 Parisa Drive
Paducah, Kentucky 42001

Signed: Laxmaiah Manchikanti, MD
Date Signed: 02/24/2006
Official Committee URL: www.sipms.org

(End FEC FORM 1)

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