2017 FLORIDA NOT FOR PROFIT CORPORATION ANNUAL REPORT

FILED
Apr 18, 2017
Secretary of State
CC8417505728

DOCUMENT# N16000010710
Entity Name: FLORIDA RURAL HOSPITAL ALLIANCE, INC.
Current Principal Place of Business:
120 SOUTH MONROE STREET
TALLAHASEE, FL 32301

Current Mailing Address:
2108 TRIANON COURT
TALLAHASSEE, FL 32308
FEI Number: 81-4365925

Certificate of Status Desired: No

Name and Address of Current Registered Agent:
MURTHA, MICHAEL P
2108 TRIANON COURT
TALLAHASSEE, FL 32308 US
The above named entity submits this statement for the purpose of changing its registered office or registered agent, or both, in the State of Florida.

SIGNATURE:
Date

Electronic Signature of Registered Agent

Officer/Director Detail :
Title

CHAIRMAN

Title

DIRECTOR

Name

PEREZ, JORGE

Name

BLAKE, MARK

Address

120 SOUTH MONROE STREET

Address

120 SOUTH MONROE STREET

City-State-Zip:

TALLAHASEE FL 32301

City-State-Zip:

TALLAHASEE FL 32301

Title

DIRECTOR

Title

DIRECTOR

Name

DEVRNJA, ROBERT DR.

Name

FLETCHER, CHRISTIAN

Address

120 SOUTH MONROE STREET

Address

120 SOUTH MONROE STREET

City-State-Zip:

TALLAHASEE FL 32301

City-State-Zip:

TALLAHASEE FL 32301

Title

DIRECTOR

Title

DIRECTOR

Name

JARQUIN, CAROLINA

Name

LAYFELD, MICHAEL

Address

120 SOUTH MONROE STREET

Address

120 SOUTH MONROE STREET

City-State-Zip:

TALLAHASEE FL 32301

City-State-Zip:

TALLAHASEE FL 32301

Title

DIRECTOR

Title

DIRECTOR

Name

NUSBAUM, PAUL

Name

REECE, GREG

Address

120 SOUTH MONROE STREET

Address

120 SOUTH MONROE STREET

TALLAHASEE FL 32301

City-State-Zip:

TALLAHASEE FL 32301

City-State-Zip:

I hereby certify that the information indicated on this report or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as if made under
oath; that I am an officer or director of the corporation or the receiver or trustee empowered to execute this report as required by Chapter 617, Florida Statutes; and that my name appears
above, or on an attachment with all other like empowered.

SIGNATURE: JORGE PEREZ
Electronic Signature of Signing Officer/Director Detail

CHAIRMAN

04/18/2017
Date