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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1006048

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1. U.S. Anesthesia Partners, Inc. Good Government Fund

    NOTE:Commmittee Name is different than previously reported

    450 E LAS OLAS BLVD SUITE 850
    FORT LAUDERDALE, FL 33301
    Email: Chris.Kelly@usap.com;Matt@MDLangley.com

    NOTE: Email address is different than previously reported

2. Date: 04/29/2015

3. FEC Committee ID #: C00574103 This committee is a separate segregated fund. Its connected organization is a

Affiliated Committees/Organizations

NONE
, ____

Custodian of Records:

Kenny Bellendir
450 E. Las Olas Blvd.
Suite 850
Fort Lauderdale, FL 33301
Title: Treasurer
Phone # (954) 909-5767

Treasurer:

Kenny Bellendir
450 E. Las Olas Blvd.
Suite 850
Fort Lauderdale, Florida 33301
Title: Treasurer
Phone # (954) 909-5767

Designated Agent(s):

Matt Langley
3011 Harrah Drive
Suite T
Spring Hill, Tennessee 37174
Title: Consultant
Phone # (615) 476-8727

Banks or Depositories

Bank of Texas
306 West Wall Street
Midland, Texas 79701

Signed: Kenny Bellendir
Date Signed: 04/29/2015
Official Committee URL: www.USAP.com

NOTE: URL is different than previously reported

(End FEC FORM 1)

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