FEC FORM 1
STATEMENT OF ORGANIZATION
FILING FEC-445435
1. PIEDMONT TRIAD ANESTHESIA P A FEDERAL PAC
145 KIMEL PARK DRIVE SUITE 120WINSTON-SALEM, NC 27103
2. Date: 01/15/2009
3. FEC Committee ID #: C00435651 This committee is a separate segregated fund. Its connected organization is a CorporationAffiliated 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. Fyock145 Kimel Park Drive
Suite 300
Winston-Salem, NC 271036972
Title: Assistant Treasurer
Phone # (336) 768-3212
Treasurer:
Dr. Frederick Alan Koontz4246 Allistair Road
Winston-Salem, North Carolina 27104
Title: Treasurer
Phone # (336) 768-3212
Designated Agent(s):
Banks or Depositories
FIRST CITIZENS BANKP.O. Box 27131
Raleigh, North Carolina 276117131
WACHOVIA BANK
100 N MAIN STREET
WINSTON-SALEM, North Carolina 27101