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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1332606

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1. Primary Care Innovation Alliance Inc. PAC (PCIA PAC)

    1950 Roland Clarke Pl Ste 300
    Reston, VA 20191
    Email: fecinfo@pass1.com

2. Date: 05/30/2019

3. FEC Committee ID #: C00664961 This committee is a separate segregated fund. Its connected organization is a Membership Organization

Affiliated Committees/Organizations

Primary Care Innovation Alliance Inc.
4950 Communication Ave Ste 100
Boca Raton, Florida 33431
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Vincent Tallman
1950 Roland Clarke Pl Ste 300
Reston, VA 20191
Title: Custodian of Records
Phone # (703) 476-3070

Treasurer:

Vincent Tallman
1950 Roland Clarke Pl Ste 300
Reston, Virginia 20191
Title: Treasurer
Phone # (703) 476-3070

Designated Agent(s):

Matt Grossman
4950 Communication Ave Ste 100
Boca Raton, Florida 33431
Title: Assistant Treasurer
Phone # (561) 982-4320

Banks or Depositories

Atlantic Union Bank
4221 Walney Road Ste 120
Chantilly, Virginia 20151

Signed: Vincent Tallman
Date Signed: 05/30/2019
Official Committee URL: None

FORM TEXT-1

(End FEC FORM 1)

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