Notification of Changes for Business Entity
General Information
Business Entity Name:	EMPOWER BROKERAGE, INC
Incorporation / Formation Date:	07/12/2007
FEIN:	260536858
Ohio License Number:	37964
NPN:	9901964
DBA / Trade Name:
State of Domicile:	TX
County:	TARRANT
Business Address
Address 1:	1100 E SOUTHLAKE BLVD
Address 2:	SUITE 100
City:	SOUTHLAKE
State:	TX
Zip:	76092
Phone:	817-410-5800
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1100 E SOUTHLAKE BLVD
Address 2:	SUITE 100
City:	SOUTHLAKE
State:	TX
Zip:	76092
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:	SHANNON CULP
Title:	COO
Phone Number:	817-410-5802
Email Address:	SCULP@EMPOWERBROKERAGE.COM