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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1023940

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1. Friends of Kip Tom

    PO Box 216
    Leesburg, IN 46538
    Email: info@kiptom.com;kassirowland@tomfarms.com

2. Date: 09/02/2015

3. FEC Committee ID #: C00585810 This committee is a Principal Campaign Committee. Candidate: Mr. Kip E Tom
Party: Republican Party
Office Sought: House of Representatives
State is Indiana in District: 03

Affiliated Committees/Organizations

NONE
, ____

Custodian of Records:

Derrick Deardorff
PO Box 216
Leesburg, IN 46538
Title: Assistant Treasurer
Phone # (574) 453-3300

Treasurer:

Patricia R Miller
PO Box 216
Leesburg, Indiana 46538
Title: Treasurer
Phone # (260) 433-1088

Designated Agent(s):

Banks or Depositories

Lake City Bank
PO Box 1387
Warsaw, Indiana 46581

Signed: Patricia R Miller
Date Signed: 09/02/2015
Official Committee URL: www.kiptom.com

(End FEC FORM 1)

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