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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-458663

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1. North Central Academy of Chiropractic C-PAC

    NOTE:Commmittee Name is different than previously reported

    115 EAST OHIO AVENUE
    SEBRING, OH 44672
    Email: drdwaine@everetthealth.com

2. Date: 04/06/2010

3. FEC Committee ID #: C00451450 This committee is a separate segregated fund. Its connected organization is a Trade Association

Affiliated Committees/Organizations

North Central Academy of Chiropractic
115 East Ohio Avenue
Sebring, Ohio 44672
Affiliated Relationship Code: Connected Organization

Custodian of Records:

DWAINE EVERETT
29950 BUCK RD
SALEM, OH 44460
Title: Treasurer
Phone # (330) 938-0001

Treasurer:

DWAINE EVERETT
29950 BUCK RD
SALEM, Ohio 44460
Title: Treasurer
Phone # (330) 938-0001

Designated Agent(s):

Banks or Depositories

Chase Bank
1100 East State St
Alliance, Ohio 44601

Signed: DWAINE EVERETT
Date Signed: 04/06/2010

(End FEC FORM 1)

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