Ohio Department of Commerce Governor Division of Real Estate & Professional Licensing th 77 South High Street • 20 Floor Columbus, OH 43215-6133 (614) 466-4100 FAX (614) 644-0584 www.com.ohio.gov REAL ESTATE Director TRUST/SPECIAL ACCOUNT CHANGE FORM Any change to your Trust or Special, non-interest bearing account information must be filed with this office utilizing this form. Trust or Special, non-interest bearing account information is verified for correctness during all Compliance Audits. This form is interactive. You may, before printing, type your responses directly onto the form. Otherwise, this form must be typewritten or printed legibly in black ink. Use this form to update the division’s records on each and every change to your trust or special, noninterest bearing account information. Attach a letter or statement from the bank at which the company’s new trust or special, non-interest bearing account is held that includes the account D.B.A. name, the account number, and a statement that the account is a non-interest bearing trust or special account. COMPANY/BROKER INFORMATION BROKER LAST NAME BROKER FIRST NAME BUSINESS NAME BROKER MIDDLE NAME FILE NUMBER DOING BUSINESS AS (D.B.A.) NAME BUSINESS ADDRESS FILE NUMBER CITY STATE ZIP CODE + 4 PREVIOUS NON-INTEREST BEARING ACCOUNT INFORMATION NAME OF BANK ACCOUNT NAME BANK ADDRESS ACCOUNT NUMBER CITY STATE ZIP CODE + 4 END DATE OF PREVIOUS ACCOUNT NEW NON-INTEREST BEARING ACCOUNT INFORMATION NAME OF BANK ACCOUNT NAME BANK ADDRESS ACCOUNT NUMBER CITY STATE ZIP CODE + 4 EFFECTIVE DATE OF NEW ACCOUNT _______________________________________ AUTHORIZED SIGNATURE DATE Be certain the attached statement from your bank indicates that this Trust or Special account is non-interest bearing. FINANCIAL INSTITUTIONS INDUSTRIAL COMPLIANCE LABOR & WORKER SAFETY LIQUOR CONTROL REAL ESTATE & PROFESSIONAL LICENSING SECURITIES STATE FIRE MARSHAL UNCLAIMED FUNDS COM 3692 (10-2003) “An Equal Opportunity Employer and Service Provider” Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com