Notification of Changes for Business Entity
General Information
Business Entity Name:	AFFINITYLTC LLC
Incorporation / Formation Date:
FEIN:	208255609
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	PA
County:	CUMBERLAND
Business Address
Address 1:	1023 MUMMA ROAD
Address 2:	SUITE 202
City:	LEMOYNE
State:	PA
Zip:	17043
Phone:	717-737-3060
Fax:
Business Web Site Address:
Business Email Address:	CORPLICENSING@LTCGLOBAL.COM
Mailing Address
Address 1:	6201 PRESIDENTIAL COURT
Address 2:
City:	FORT MYERS
State:	FL
Zip:	33919
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:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
STEVEN A. HENSLEY	RDA	17541051	YES		01/09/2017
MICHAEL S. VANGAVREE	RDA	9057244		YES	01/09/2017

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:	LINDA POWELL
Title:	DIRECTOR OF COPORATE CONTRACTS
Phone Number:	800-362-8837 EXT 1303
Email Address:	LPOWELL@LTCGLOBAL.COM