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

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-983587

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

20 F Street NW
Suite 700
Washington, DC 20001

NOTE: Address is different than previously reported

Email: emassey@siia.org;jivy@siia.org

2. Date: 01/14/2015

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)
20 F Street NW
Suite 700
Washington, DC 20001
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

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-983587

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

NOTE: Address is different than previously reported

2. Date: 01/14/2015

Affiliated Committees/Organizations

Custodian of Records:

Treasurer:

Designated Agent(s):

Banks or Depositories

Signed: Mike Ferguson
Date Signed: 01/14/2015

(End FEC FORM 1)

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-983587

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

NOTE: Address is different than previously reported

2. Date: 01/14/2015

Affiliated Committees/Organizations

Custodian of Records:

Treasurer:

Designated Agent(s):

Banks or Depositories

Signed: Mike Ferguson Date Signed: 01/14/2015

(End FEC FORM 1)

Signed: Mike Ferguson
Date Signed: 01/14/2015