Notification of Changes for Business Entity
General Information
Business Entity Name:	PROSPERA LIFE & ANNUITY SERVICES, INC.
Incorporation / Formation Date:
FEIN:	752225660
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	TX
County:	DALLAS
Business Address
Address 1:	5429 LBJ FREEWAY, SUITE 400
Address 2:
City:	DALLAS
State:	TX
Zip:	75240
Phone:	972-581-3000
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	5429 LBJ FREEWAY, SUITE 400
Address 2:
City:	DALLAS
State:	TX
Zip:	75240
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
JAY SLOUFFMAN	PRODUCER	6082184	YES		5-8-2018

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
DELMIRA BUTLER

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:	DELMIRA BUTLER
Title:	COMPLIANCE SPECIALIST
Phone Number:	2547296129
Email Address:	DBUTLER@ILSAINC.COM