St. John the Baptist Parish                                         *Enter Information in          OFFICIAL USE ONLY
                                                                       Boxes Only
   CHANGE OF STATUS REPORT                                                                   ACCOUNT NUMBER:
                                                                                             RECORDED BY:                              DATE:
   Type of Change:                     A. Business discontinued/closed                       B. Change of name

Effective date of change:              C. Change of mailing and/or physical address          D. Change of entity type

                                       E. Business sold*

   *Name of new owner:

A. Reason for closure:

B. New Legal Name of business:

   New Trade Name of business:

C. New Physical Address:
                                       Physical Address                City         State    Zip code           Phone                       Parish

   New Mailing Address:
   (If same as physical. write "same") Mailing Address                 City         State    Zip code           Phone                       Parish

D. New Type of Organization:
                                       Individual       Corporation    LLC                         Non-Profit

                                       Partnership      LLP            Government                  Other >
                          I affirm that the information given on this application is complete, true and correct.

Signature of Applicant:                                                                      Title:

Signature of Preparer:                                                                       Date: