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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1514827

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1. ModivCare Inc. Political Action Committee

    4700 S Syracuse Suite 440
    Denver, CO 80237
    Email: fecinfo@pass1.com;heath.sampson@modivcare.com

2. Date: 04/30/2021

3. FEC Committee ID #: C00754077 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

Committee ID# C00754077
ModivCare Inc.
4700 S Syracuse Suite 440
Denver, Colorado 80237
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Kenneth Shepard
4700 S Syracuse Suite 440
Denver, CO 80237
Title: Custodian of Records
Phone # (404) 888-5800

Treasurer:

Heath Sampson
4700 S Syracuse Suite 440
Denver, Colorado 80237
Title: Treasurer
Phone # (404) 888-5800

Designated Agent(s):

Kenneth Shepard
4700 S Syracuse Suite 440
Denver, Colorado 80237
Title: Assistant Treasurer
Phone # (404) 888-5800

Banks or Depositories

Bank of America
100 N Tryon St
Charlotte, North Carolina 28255

Signed: Heath Sampson
Date Signed: 04/30/2021

FORM TEXT-1

(End FEC FORM 1)

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