Notification of Changes for Business Entity
General Information
Business Entity Name:	RFA INC
Incorporation / Formation Date:
FEIN:	752438953
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	TX
County:	SMITH
Business Address
Address 1:	821 EAST SOUTH EAST LOOP 323, STE 200
Address 2:
City:	TYLER
State:	TX
Zip:	75701
Phone:	903-581-2600
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	821 EAST SOUTH EAST LOOP 323, STE 200
Address 2:
City:	TYLER
State:	TX
Zip:	75701
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
DENISE ANDREW	RDA	8803174	YES		06/23/2017
DONNA CLARK	RDA	1969726		YES	06/23/2017

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
DENISE ANDREW	VICE PRESIDENT	8803174	YES		06/23/2017
DONNA CLARK	VICE PRESIDENT	1969726		YES	06/23/2017

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)
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?
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:	JANNA BELL
Title:	LICENSING ADMINISTRATOR
Phone Number:	812-886-0191
Email Address:	JBELL@SUPPORTIVEIS.COM