MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS GROUP TRUST MEMBER INFORMATION UPDATE Group Trust Name Group Trust Acronym Member Name 3315 W. Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 573-751-4231 www.labor.mo.gov/DWC d.b.a. A change of address or ownership must be provided to the division within thirty (30) days of the change. 8 CSR 50-3.010(6)(A)10. CHANGE IN:  Name  FEIN  Address  d.b.a.  Primary or Mailing Address Change From: ________________________________ ________________________________ ________________________________ ________________________________ Change To: ________________________________ ________________________________ ________________________________ ________________________________ Effective Date: ___________________ ADD:  FEIN  Address  d.b.a. CHANGE IN:  Name  FEIN  Address  d.b.a.  Primary or Mailing Address Change From: ________________________________ ________________________________ ________________________________ ________________________________ Change To: ________________________________ ________________________________ ________________________________ ________________________________ Effective Date: ___________________ ADD: ________________________________ ________________________________ ________________________________ ________________________________ Effective Date: ___________________ REMOVE:  FEIN  Address  d.b.a. ________________________________ ________________________________ ________________________________ ________________________________ Effective Date: ___________________  FEIN  Address  d.b.a. ________________________________ ________________________________ ________________________________ ________________________________ Effective Date: ___________________ REMOVE:  FEIN  Address  d.b.a. ________________________________ ________________________________ ________________________________ ________________________________ Effective Date: ___________________ ADDITIONAL NOTES: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ WC-270 (03-12) AI American LegalNet, Inc. www.FormsWorkFlow.com