Sec. 426.201 Wis. Stats. STATE OF WISCONSIN DEPARTMENT OF FINANCIAL INSTITUTIONS Type: Index No: Invoice No: Due Date February 28, 2011 For Reporting Period 1/1/10 to 12/31/10 WISCONSIN CONSUMER ACT REGISTRATION - ANNUAL Please review information listed below and make any necessary corrections. Information not pre-printed should be completed. Name, title and address of person responsible for completing this form, along with name of business: Phone Number: Fax Number: Street address of principal office, if different from above: City: State: Fax Number: Zip Code: Phone Number: Name of business if operating with a name other than that listed above: If you have offices or retail stores in Wisconsin, list the name and address of each location on a separate sheet of paper and attach to this form. If credit sales, leases or loans are entered into with Wisconsin residents, other than at physical locations in Wisconsin, indicate the manner they are made by checking the appropriate boxes. Phone Internet Postal Mailing In Another State Other _______________________ Name of registered agent, if any: Agent street address: State: Zip Code: City: Phone Number: Fax Number: Outstanding balance of all Wisconsin consumer credit transactions as of December 31, 2010. $___________________ NOTE: If you will be paying the maximum fee of $2,800 it is not necessary to report the outstanding balance. Fee Due is the greater of 1) $25 or 2) your outstanding balance of all Wisconsin consumer credit transactions as of December 31, 2010, multiplied by the assessment rate of .00006. If your outstanding balance is less than $250,000 return this form but you are not required to pay a fee. The maximum fee is $2,800. Make check payable to: DFI-BCA. Fee Due = $___________________ You may check this box if your outstanding balance at December 31, 2010 is $250,000 or less and you believe your 12/31/11 balance will also be under $250,000. If checked, we will not send you this form next year (calendar year 2011). You are not required to file this form for subsequent years if your year-end balance for those years is under $250,000. If checked, you agree to notify our Department when your December 31 balance exceeds $250,000 in any future year. I hereby certify under penalty of Section 946.32, Wisconsin Statutes, that the statements in this registration are true and correct to the best of my knowledge and belief. If information in this registration becomes inaccurate after filing, such change shall be promptly forwarded to the Department of Financial Institutions – BCA at the address on reverse side. Authorized Signature: DFI/BCA/400B (12/10) Printed Name: (See Reverse Side) Title: 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com WISCONSIN CONSUMER ACT REGISTRATION INSTRUCTIONS Who Must File What is Considered a Consumer Credit Transaction Any business that makes or solicits consumer credit transactions or directly collects payments from, or enforces rights against customers arising from such transactions, wherever made, is subject to the registration filing statutes. You must file a registration and submit a $25 fee within 30 days of commencing business in Wisconsin. Future filing is required annually only if your outstanding balance of all Wisconsin consumer credit transactions as of December 31 is over $250,000. A business solely honoring credit cards issued by a third party not related to the business is not required to file. A consumer credit transaction is any loan, lease or sale with a Wisconsin resident primarily made for a personal, family or household purpose on which a finance charge is or may be assessed, or is payable in more than four installments. Examples of consumer credit transactions are, but are not limited to:  student loans;  credit card accounts;  single-pay notes where interest is assessed;  account receivables that are payable in more than four installments or on which a finance charge is assessed;  second mortgages if the institution holding the second mortgage does not hold the first mortgage; and  checking account overdraft protection programs, if the money placed in the consumer’s account must be repaid with interest. Examples of credit transactions that do not need to be reported on this registration are credit transactions that:  are made primarily for an agricultural or business purpose;  are secured by first lien real estate mortgages;  had an original amount financed exceeding $25,000. Acknowledgment Penalties If you want an acknowledgment of your registration filing mailed to you, enclose a self-addressed, postage pre-paid envelope when submitting your registration form. If you want an electronic acknowledgment, provide your email address here: _________________________________. Failure to comply with the registration requirements under Sec. 426.201, Wis. Stats., or failure to pay a fee required under Sec. 426.202, Wis. Stats., may result in a forfeiture of not more than $50 for each day of noncompliance. Mail Registration and Payment to: Dept of Financial Institutions - BCA P.O. Box 8041 Madison, WI 53708-8041 Street address for courier use: Dept of Financial Institutions - BCA 345 W. Washington Ave. 3rd Floor Madison, WI 53703-2701 Phone: Fax: TTY: Web: (608) 264-7969 (608) 264-7968 (608) 266-8818 www.wdfi.org This document is available at www.wdfi.org/wca/forms.htm and can be made available in alternate formats upon request to qualifying individuals with disabilities. Information requested may be used for secondary purposes. DFI/BCA/400B (12/10) (See Reverse Side) 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com