Form Dfi/corp21a - Supplement - Certificate Of Authority Application

Form Dfi/corp21a - Supplement - Certificate Of Authority Application - 2000

Sec.

State of Wisconsin

180.1503

DEPARTMENT OF FINANCIAL INSTITUTIONS

Wis. Stats.

Division of Corporate & Consumer Services

SUPPLEMENT - CERTIFICATE OF AUTHORITY APPLICATION (Form 21)

The following information is required if item 8 of the application (Form 21) 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? ______________________ 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 2. The capital

represented in Wisconsin for that year was $ _________________ (from item A

(11) of the worksheet on page 2 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 $2 per $1,000 of representation over $60,000

$ ________

PLUS annual report fee for each year (Each calendar year x fee)

$ ________

1964 thru 1969 $10; 1970 thru 1977, $15; 1978 thru 1980, $17;

___________

1981 thru 1983, $25; 1984, $28; 1985, $25; 1986, $26; 1987

thru 1990, $30; and 1991 thru ____, $50.

Subtotal

$ ________

(Post subtotal

to Section II)

II.

COMPUTATION OF FILING FEE based on Supplemental Form 21-A

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)

$ __________

21A

DFI/CORP

(R8/00) Use of this form is mandatory. (Earlier editions, 1991 or later, may be used)

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Form Dfi/corp21a - Supplement - Certificate Of Authority Application - 2000

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