Notification of Changes for Business Entity
General Information
Business Entity Name:	DAIRY GROSS MARGIN, LLC
Incorporation / Formation Date:
FEIN:	26-1505518
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	IA
County:	USA
Business Address
Address 1:	1422 CENTRAL AVE
Address 2:
City:	FORT DODGE
State:	IA
Zip:	50501
Phone:	515-955-5200
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1422 CENTRAL AVE
Address 2:
City:	FORT DODGE
State:	IA
Zip:	50501
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
STEVE NICKLAUS	OWNER	481585772		YES	12/6/2018

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)	NO
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?	NO
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	RONALD MORTENSEN
Title:	OWNER
Phone Number:	515-955-5265
Email Address:	RON@ADVANTAGEAG.COM