Sec. 180.1503
State of Wisconsin
Wis. Stats.
DEPARTMENT OF FINANCIAL INSTITUTIONS
Division of Corporate & Consumer Services
SUPPLEMENT - CERTIFICATE OF AUTHORITY APPLICATION
The following information is required if item 8 of the application indicates that the corporation has
transacted business in Wisconsin without holding a certificate of authority.
Name of
State of
Corporation:
Incorporation:
I. During what period did the corporation transact business in Wisconsin without holding a certificate
of authority?
(date range).
Complete items 1, 2 and 3 below, and post the subtotal of fees to item II.
1. The capital the corporation expects to have represented in Wisconsin in the
coming year is $ _________________(from item 12 A (11) – Form 21).
2. In what year during the period in which the corporation transacted business
without a certificate of authority did the corporation have the highest capital
representation? ___________. Complete the worksheet on page 6. The capital
represented in Wisconsin for that year was $ _________________ (from item A
(11) of the worksheet on page 6 of this form).
3. Enter the greater amount of the capital representation from item 1 or 2, above.
$ __________________. Compute the following fees based on this figure.
Fee for the first $60,000 of representation.
$
100.00
PLUS $3 per $1,000 of representation over $60,000.
$ ________
PLUS annual report fee for each calendar year, beginning with
$ ________
the calendar year following that in which the corporation first transacted
___________
business in Wisconsin. In making your computation include the report fee
for the current calendar year, unless it is the first year in which the corporation
transacted business in Wisconsin.
1964 thru 1969 $10; 1970 thru 1977, $15; 1978 thru 1980, $17;
1981 thru 1983, $25; 1984, $28; 1985, $25; 1986, $26; 1987
Subtotal
$ ________
thru 1990, $30; 1991 thru 2001, $50; and 2002 thru
, $65.
(Post subtotal
to Section II)
II.
COMPUTATION OF FILING FEE based on Supplemental Form 21S
Subtotal from the section above.
$ __________
Calculate and add a 50% penalty to the subtotal, or $5,000, whichever is less.
$ __________
TOTAL FILING FEE (post to item 15 on Form 21, pg 4)
$ __________
DFI/CORP21S(R11/12)
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