FEC Form 1 for PIEDMONT TRIAD ANESTHESIA P A FEDERAL PACForm 1 for PIEDMONT TRIAD ANESTHESIA P A FEDERAL PAC

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1009793

1. PIEDMONT TRIAD ANESTHESIA P A FEDERAL PAC

145 KIMEL PARK DRIVE SUITE 120
WINSTON-SALEM, NC 27103
Email: tfyock@ptanc.com;kshircliffe@ptanc.com

NOTE: Email address is different than previously reported

2. Date: 06/08/2015

3. FEC Committee ID #: C00435651 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

PIEDMONT TRIAD ANESTHESIA, P.A.
145 KIMEL PARK DRIVE
SUITE 120
WINSTON-SALEM, North Carolina 271036972
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Mr. Theodore C. Fyock
145 Kimel Park Drive
Suite 300
Winston-Salem, NC 271036972
Title: Treasurer
Phone # (336) 768-3212

Treasurer:

Mr. Theodore C. Fyock
145 Kimel Park Drive
Suite 300
Winston-Salem, North Carolina 271036972
Title: Treasurer
Phone # (336) 768-3212

Designated Agent(s):

McNeil Cronin
145 Kimel Park Drive
Suite 120
Winston-Salem, North Carolina 27103
Title: Assistant Treasurer
Phone # (336) 768-1212

Banks or Depositories

WELLS FARGO
100 N MAIN STREET
D 4001-052
WINSTON-SALEM, North Carolina 27101

Signed: Mr. Theodore C. Fyock
Date Signed: 06/08/2015

(End FEC FORM 1)

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