FEC Form 1 for Surgery Partners Political Action CommitteeForm 1 for Surgery Partners Political Action Committee

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1013009

1. Surgery Partners Political Action Committee

NOTE:Commmittee Name is different than previously reported

40 Burton Hills Boulevard
Suite 500
Nashville, TN 37215
Email: dbell@surgerypartners.com;swhitmore@surgerypartners.com

NOTE: Email address is different than previously reported

2. Date: 07/09/2015

3. FEC Committee ID #: C00520833 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

Surgery Partners, Inc.
40 Burton Hills Blvd
Suite 500
Nashville, Tennessee 37215
Affiliated Relationship Code: Connected Organization

Committee ID# C00428086
NOVAMED INC POLITICAL ACTION COMMITTEE
333 W WACKER DRIVE SUITE 1010
CHICAGO, Illinois 60606
Affiliated Relationship Code: Affiliated Committee

Custodian of Records:

Mr. Derek Edward Bell
40 Burton Hills Blvd.
Suite 400
Nashville, TN 37215
Title: Treasurer
Phone # (615) 234-5911

Treasurer:

Mr. Derek Edward Bell
40 Burton Hills Blvd.
Suite 400
Nashville, Tennessee 37215
Title: Treasurer
Phone # (615) 234-5911

Designated Agent(s):

Steve Whitmore
40 Burton Hills Boulevard
Suite 500
Nashville, Tennessee 37215
Title: Assistant Treasurer
Phone # (615) 234-7916

Banks or Depositories

Bank of America
4011 Hillsboro Road
Nashville, Tennessee 37215

Signed: Mr. Derek Edward Bell
Date Signed: 07/09/2015
Official Committee URL: www.surgerypartners.com

NOTE: URL is different than previously reported

(End FEC FORM 1)

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