Notification of Changes for Business Entity
General Information
Business Entity Name:	CCC VAN WERT CREDIT UNION
Incorporation / Formation Date:	08/09/2006
FEIN:	034-1123
Ohio License Number:
NPN:	8883210
DBA / Trade Name:
State of Domicile:	OH
County:	VAN WERT
Business Address
Address 1:	1296 W. MAIN STREET
Address 2:
City:	VAN WERT
State:	OH
Zip:	45891
Phone:	419-238-5241
Fax:
Business Web Site Address:
Business Email Address:	CCCVANWERTCREDITUNION@CENTURYLINL.NET
Mailing Address
Address 1:	1296 W MAIN STREET
Address 2:
City:	VAN WERT
State:	OH
Zip:	45891
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
CHRISTINA RODRIGUEZ	OFFICE MANAGER	8883210	YES		03/09/2017
CATHERINE JOSEPH	TREASURER	8878848	YES		03/09/2017
DEBORAH DICKSON	ASST OFFICE MANAGER	283645723	YES		03/09/2017

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)	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:	CHRISTINA M RODRIGUEZ
Title:	OFFICE MANAGER
Phone Number:	419-238-5241
Email Address:	CCCVANWERTCREDITUNION@CENTURYLINK.NET