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State of Wisconsin

DEPARTMENT OF FINANCIAL INSTITUTIONS

Division of Corporate & Consumer Services

OPTIONAL INFORMATION:

11. Delayed Effective Date, If applicable:

Subject to the conditions set forth in

s. 183.0110

and

183.0111 Wis.

Stats., a document filed by the department under Ch. 183 is

effective on the date it is received by the department for filing, unless a delayed (future) effective date is declared in the document.

To name a delayed effective date, enter the future effective date on the appropriate space on the form. The delayed effective

date may not be more than 90 days after the date the document is received by the department.

12. Enter your contact information, so we may send you an acknowledgement of this filing. You may optionally include an email

address and a phone number where we may reach you for questions.

SUPPLEMENT CALCULATION HELP:

A foreign limited liability company that transacts business in Wisconsin without a certificate of registration is liable to Wisconsin

for each year or any part of a year during which it transacted business in Wisconsin without a certificate of registration, in an

amount equal to the sum of the following:

All fees that would have been imposed by this chapter upon the foreign limited liability company had it applied for and

received a certificate of registration.

Fifty percent of the amount owed under

s. 183.103(5)(a)1

or $5,000, whichever is less.

Do NOT include an annual report fee for the current calendar year. This will be paid on your next annual report that is due by the

end of the 1

quarter of each year.

SUPPLEMENT EXAMPLE

This sample calculation is for a company who has been doing business in Wisconsin since 1998, but didn’t file the

application until 2015, in doing so they do not count the current calendar year.

1998

In what year did you begin transacting business in Wisconsin?

$100.00

Basic Registration Fee

Base Fee

Annual report fees for each year:

1995 thru 2001:

# of years x

$50.00

$ 200.00

2002 thru last calendar year:

# of years x

$80.00

$1,040.00

Subtotal =

$1,340.00

(Base fee + annual report fees)

Add 50% penalty fee on the Subtotal, or $5,000, whichever is less:

Penalty Fee

$ 670.00

Total Filing Fee =

$2,010.00

(Subtotal + penalty fee)

NONREFUNDABLE FILING FEE:

Institutions. Optional expedited service: The

Make total remittance payable to the

Department of Financial

nonrefundable expedited service fee of $25.00 is in addition to the filing fee required for this document to be processed, and provides the document

will be processed in an expeditious manner.

This form may be used to accomplish a filing with the department. Information requested may be used for secondary purposes. This document can be made available in

alternate formats upon request to qualifying individuals with disabilities.

Mailing Address:

Physical Address for Express Mail/Courier

State of WI – Dept. of Financial Institutions

Department of Financial Institutions

Box 93348

Division of Corporate & Consumer Services

Milwaukee WI 53293-0348

201 W. Washington Ave – Suite 300

Madison WI 53703

DFI/CORP/FORM 521-I (10/15)

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Form 521-I - Limited Liability Company Application For Certificate Of Registration Information And Instructions Page 2

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