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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1039231

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1. Genoa PAC (A PAC of Genoa-a QoL Healthcare Company LLC)

    18300 Cascade Ave. South Ste 251
    Tukwila, WA 98188
    Email: vbreed@genoa-qol.com;qkline@genoa-qol.com

2. Date: 01/08/2016

3. FEC Committee ID #: C00603373 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

Genoa-A QoL Healthcare Company LLC
18300 Cascade Ave. South Ste 251
Tukwila, Washington 98188
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Quintina Kline
1541 Runnymede Rd
Oakwood, OH 45419
Title: Assistant Treasurer
Phone # (937) 952-0338

Treasurer:

Victor Breed
18300 Cascade Ave. South Ste 251
Tukwila, Washington 98188
Title: Treasurer
Phone # (425) 679-5696

Designated Agent(s):

Quintina Kline
154 Runnymede Rd
Oakwood, Ohio 45419
Title: Assistant Treasurer
Phone # (937) 952-0338

Banks or Depositories

Access National Bank
1800 Robert Fulton Drive
Reston, Virginia 20191

Signed: Victor Breed
Date Signed: 01/12/2016
Official Committee URL: None

(End FEC FORM 1)

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