Notification of Changes for Business Entity
General Information
Business Entity Name:	NATHAN YOUNG INSURANCE AGENCY LLC
Incorporation / Formation Date:	12/07/2009
FEIN:	27-1366362
Ohio License Number:
NPN:	17436722
DBA / Trade Name:
State of Domicile:	OH
County:	WOOD
Business Address
Address 1:	674 W BOUNDARY
Address 2:
City:	PERRYSBURG
State:	OH
Zip:	43551
Phone:	4198747966
Fax:	8558058738
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	674 W BOUNDARY
Address 2:
City:	PERRYSBURG
State:	OH
Zip:	43551
Indicate the type of change you are seeking
Address Change:	YES
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:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date

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:	NATHAN YOUNG
Title:	OWNER
Phone Number:	4198747966
Email Address:	NYOUN2@AMFAM.COM