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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-896655

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1. JACKSON LEWIS P.C. POLITICAL ACTION COMMITTEE

    NOTE:Commmittee Name is different than previously reported

    ONE NORTH BROADWAY
    14th FLOOR
    WHITE PLAINS, NY 10601
    Email: schlossw@jacksonlewis.com

2. Date: 12/03/2013

3. FEC Committee ID #: C00482570 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

JACKSON LEWIS P.C.
ONE NORTH BROADWAY
14th FLOOR
WHITE PLAINS, New York 10601
Affiliated Relationship Code: Connected Organization

Custodian of Records:

WILLIAM A SCHLOSSER
ONE NORTH BROADWAY
14th FLOOR
WHITE PLAINS, NY 10601
Title: CFO
Phone # (914) 328-0404

Treasurer:

WILLIAM A SCHLOSSER
ONE NORTH BROADWAY
14th FLOOR
WHITE PLAINS, New York 10601
Title: CFO
Phone # (914) 328-0404

Designated Agent(s):

STEPHEN LASKA
ONE NORTH BROADWAY
14th FLOOR
WHITE PLAINS, New York 10601
Title: ASSISTANT TREASURER
Phone # (914) 328-0404

Banks or Depositories

Citibank
244 Main Street
White Plains, New York 10601

Signed: WILLIAM A SCHLOSSER
Date Signed: 12/03/2013

(End FEC FORM 1)

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