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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-872242

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1. Self-Insurance Institute of America, Inc. PAC (Self-Insurance PAC)

    1250 H Street, NW Suite 901
    Washington, DC 20005
    Email: emassey@siia.org

    NOTE: Email address is different than previously reported

2. Date: 05/22/2013

3. FEC Committee ID #: C00457366 This committee is a separate segregated fund. Its connected organization is a Trade Association
     In addition, this committee is a Lobbyist/Registrant PAC.

Affiliated Committees/Organizations

Committee ID# C00457366
Self-Insurance Institute of America, Inc. PAC (Self-Insurance PAC)
1250 H Street, NW Suite 901
Washington, DC 20005
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Mike Ferguson
7 Cedar Glenn Way
Simpsonville, SC 29681
Title: Director
Phone # (202) 463-8161

Treasurer:

Mike Ferguson
7 Cedar Glenn Way
Simpsonville, South Carolina 29681
Title: Director
Phone # (202) 463-8161

Designated Agent(s):

Jay Fahrer
1250 H Street, NW Suite 901
Washington, DC 20005
Title: Assistant Treasurer
Phone # (202) 463-8161

Banks or Depositories

Sun Trust Bank
1100 G Street, NW
Washington, DC 20005

Signed: Mike Ferguson
Date Signed: 05/22/2013

(End FEC FORM 1)

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