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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-764841

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1. Advocat Inc. Political Action Committee

    1621 Galleria Blvd
    Brentwood, TN 37027
    Email: scarter@advocat-inc.com

2. Date: 02/07/2012

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

Affiliated Committees/Organizations

Advocat, Inc.
1621 Galleria Blvd.
Brentwood, Tennessee 37027
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Sam Daniel
1621 Galleria Blvd
Brentwood, TN 370272926
Title: Custodian of Records
Phone # (615) 771-7575

Treasurer:

Kelly J. Gill
1621 Galleria Blvd
Brentwood, Tennessee 370272926
Title: Treasurer
Phone # (615) 771-7575

Designated Agent(s):

Sam Daniel
1621 Galleria Blvd
Brentwood, Tennessee 370272926
Title: Assistant Treasurer
Phone # (615) 771-7575

Banks or Depositories

Regions Bank
Mallory Lane
1729 Mallory Ln
Brentwood, Tennessee 370270.00

Signed: Kelly J. Gill
Date Signed: 02/07/2012

(End FEC FORM 1)

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