Form Dfi/corp21s - Supplement - Certificate Of Authority Application - 2012 Page 2
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2WORKSHEET FOR DETERMINING CAPITAL REPRESENTED IN WISCONSIN
(Supplemental Form 21S)
Compute the proportion of capital represented in Wisconsin during the year cited in item 2, on
page 5, using either a calendar or fiscal year basis. (NOTE: Start by completing items A(1) thru A(7).
Continue, and in sequence, first complete item B and next item C, as each or both may be necessary,
and post the results to item A and complete the computations in item A. Corporations having both Par
Value and No Par Value shares issued will utilize both item B and item C.
A.(1) Gross Business
$_____________
(2) Plus Total Assets
$_____________
(3) Total of lines (1) and (2)
$_____________
(4) Wisconsin business
$_____________
(5) Plus Wisconsin Assets
$_____________
(6) Total of lines (4) and (5)
$_____________
(7) Divide line (6) by line (3) and
enter percentage
___________%
(8) Value of Issued Shares of PAR VALUE
stock from item B (3)
$_____________
(9) Value of Issued Shares of NO PAR
VALUE stock from line C (7)
$_____________
(10) Total of lines (8) and (9)
$_____________
(11) Multiply line (10) by line (7) and enter the product
here and in item 2 on page 5 of this form
$ _____________
B. PAR VALUE STOCK (Use this section to compute valuation of Par Value stock only)
(1) Value of issued shares of Par Value stock,
computed at PAR
$_____________
(2) Paid-in capital, in excess of Par, applicable
to issued shares of Par Value stock
$_____________
(3) Total of lines (1) and (2). Also enter
$_____________
this sum on line A (8) above
C. NO PAR VALUE STOCK (Use this section to compute valuation of No Par Value stock only)
(1) Total assets (From item A.(2) above.)
$_____________
(2) Deduct liabilities other than capital and
Surplus
$_____________
(3) Total of line (1) minus line (2)
$_____________
(4) Deduct amount of line A (8) above
$_____________
(5) Remainder of line (3) minus line (4)
$_____________
(6) Compute value of issued shares of NO PAR
VALUE stock at $10.00 per share
$_____________
(7) Enter the GREATER of line (5) or line (6) here. Also
$_____________
enter this sum on line A (9) above.
21S
DFI/CORP
(R11/12)
6
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