Notification of Changes for Business Entity
General Information
Business Entity Name:	HOMELAND@WORK, LLC
Incorporation / Formation Date:
FEIN:	46-2706522
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	TX
County:	TX
Business Address
Address 1:	825 WATTERS CREEK BLVD.
Address 2:	SUITE 300
City:	ALLEN
State:	TX
Zip:	75013
Phone:	2148712118
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	825 WATTERS CREEK BLVD. SUITE 300
Address 2:
City:	ALLEN
State:	TX
Zip:	75013
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
ABE ABTAHI	AGENT	969820		YES	11/18/16
KALEESHA STRANGE	AGENT	819257		YES	11/18/16
CONSUELA REESE	AGENT	10924407		YES	11/18/16

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:	JULIET BELL
Title:	LICENSING MANAGER
Phone Number:	4693245240
Email Address:	LICENSING@HOMELANDHEALTHCARE.COM