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-445435

1. PIEDMONT TRIAD ANESTHESIA P A FEDERAL PAC

145 KIMEL PARK DRIVE SUITE 120
WINSTON-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 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: Assistant Treasurer
Phone # (336) 768-3212

Treasurer:

Dr. Frederick Alan Koontz
4246 Allistair Road
Winston-Salem, North Carolina 27104
Title: Treasurer
Phone # (336) 768-3212

Designated Agent(s):

Banks or Depositories

FIRST CITIZENS BANK
P.O. Box 27131
Raleigh, North Carolina 276117131

WACHOVIA BANK
100 N MAIN STREET
WINSTON-SALEM, North Carolina 27101

Signed: Mr. Theodore C. Fyock
Date Signed: 01/18/2010

(End FEC FORM 1)

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