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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1335658

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1. HY-VEE INC EMPLOYEES' POLITICAL ACTION COMMITTEE

    5820 WESTOWN PARKWAY
    WEST DES MOINES, IA 50266
    Email: jkrajicek@hy-vee.com;mbellinghausen@hy-vee.com

    NOTE: Email address is different than previously reported

2. Date: 04/28/2014

3. FEC Committee ID #: C00243659 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

Hy-Vee, Inc.
5820 Westown Pkwy
West Des Moines, Iowa 50266
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Jeremy Krajicek
3061 SW Arlan Ln
Ankeny, IA 50023
Title: Treasurer
Phone # (515) 267-2800

Treasurer:

Jeremy Krajicek
3061 SW Arlan Ln
Ankeny, Iowa 50023
Title: Treasurer
Phone # (515) 267-2800

Designated Agent(s):

Michael Bellinghausen
895 SW Bobwhite Ln
Waukee, Iowa 50263
Title: Designated Agent
Phone # (515) 267-2800

Banks or Depositories

Midwest Heritage Bank
1025 Brandon Avenue
Chariton, Iowa 50049

Signed: Jeremy Krajicek
Date Signed: 06/25/2019

(End FEC FORM 1)

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