Notification of Changes for Business Entity
General Information
Business Entity Name:	H&R BLOCK INSURANCE AGENCY, INC.
Incorporation / Formation Date:
FEIN:	260631461
Ohio License Number:	36726
NPN:	9588610
DBA / Trade Name:
State of Domicile:	DE
County:	WILMINGTON
Business Address
Address 1:	1 H AND R BLOCK WAY
Address 2:
City:	KANSAS CITY
State:	MO
Zip:	64105
Phone:	8168544205
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1 H AND R BLOCK WAY
Address 2:
City:	KANSAS CITY
State:	MO
Zip:	64105
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
THAO NGUYEN	PRODUCER	17782416	YES		12/4/2015

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)
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:	CINDY DWIGANS
Title:	PARALEGAL
Phone Number:	816-360-4396
Email Address:	CDWIGANS@POLSINELLI.COM