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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1040976

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1. AmSurg Corp. Good Government Fund

    1A Burton Hills
    Nashville, TN 37215

    NOTE: Address is different than previously reported

    Email: goodgovernmentfund@amsurg.com;matt@mdlangley.com

2. Date: 01/20/2016

3. FEC Committee ID #: C00484410 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

AmSurg Corp.
1A Burton Hills Blvd.
Nashville, Tennessee 37215
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Thomas M. Sloan, Jr.
213 Timberline Court
Franklin, TN 37069
Title: Treasurer
Phone # (615) 665-3608

Treasurer:

Thomas M. Sloan, Jr.
213 Timberline Court
Franklin, Tennessee 37069
Title: Treasurer
Phone # (615) 665-3608

Designated Agent(s):

Banks or Depositories

Bank of America
414 Church Street
Nashville, Tennessee 37219

Signed: Thomas M. Sloan, Jr.
Date Signed: 01/20/2016
Official Committee URL: www.amsurg.com

(End FEC FORM 1)

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