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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1627630

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1. Diversicare Healthcare Inc. Political Action Committee

    1621 Galleria Blvd
    Brentwood, TN 37027
    Email: MWeishaar@dvcr.com;outsourcing@aristotle.com

    NOTE: Email address is different than previously reported

2. Date: 08/26/2022

3. FEC Committee ID #: C00421735 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

Diversicare Healthcare Inc.
1621 Galleria Blvd
Brentwood, Tennessee 370272926
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Matthew J. Weishaar
1621 Galleria Boulevard
Brentwood, TN 370272926
Title: Custodian of Records
Phone # (615) 771-7575

Treasurer:

Matthew J. Weishaar
1621 Galleria Boulevard
Brentwood, Tennessee 370272926
Title: Treasurer
Phone # (615) 771-7575

Designated Agent(s):

Derek McLaren
1621 Galleria Boulevard
Brentwood, Tennessee 370272926
Title: Designated Agent
Phone # (615) 771-7575

Banks or Depositories

CIBC BANK
120 South LaSalle Street
Chicago, Illinois 60603

Regions Bank
Mallory Lane
1729 Mallory Ln
Brentwood, Tennessee 37027

Signed: Matthew J. Weishaar
Date Signed: 08/26/2022

FORM TEXT-1

(End FEC FORM 1)

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