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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-905551

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1. Independence Blue Cross PAC (IBC PAC)

    1901 Market Street
    Philadelphia, PA 19103
    Email: corinne.vile@ibx.com

2. Date: 01/31/2014

3. FEC Committee ID #: C00450056 This committee is a separate segregated fund. Its connected organization is a Corporation W/O Capital Stock
     In addition, this committee is a Lobbyist/Registrant PAC.

Affiliated Committees/Organizations

Committee ID# C00450056
Independence Blue Cross
1901 Market Street
Philadelphia, Pennsylvania 19103
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Juan Lopez
1901 Market Street
Philadelphia, PA 19103
Title: Treasurer
Phone # (215) 241-2851

Treasurer:

Juan Lopez
1901 Market Street
Philadelphia, Pennsylvania 19103
Title: Treasurer
Phone # (215) 241-2851

Designated Agent(s):

Stephen P. Fera
1901 Market Street
Philadelphia, Pennsylvania 19103
Title: Assistant Treasurer
Phone # (215) 241-3027

Banks or Depositories

Wells Fargo
1339 Chestnut Street
Philadelphia, Pennsylvania 19107

Signed: Juan Lopez
Date Signed: 01/31/2014

(End FEC FORM 1)

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