. Sec. 426.201, Wis. Stats. STATE OF WISCONSIN DEPARTMENT OF FINANCIAL INSTITUTIONS Type: Index No: First-Time Filers Only WISCONSIN CONSUMER ACT REGISTRATION - INITIAL You must file this registration and submit a $25 fee within 30 days of commencing business in Wisconsin. Make check payable to the Department of Financial Institutions-OCA. Note: 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. Name of Business: Street Address of Principal Office: State: Zip Code: Phone Number: City: Fax Number: Name of Business if operating with a name different from above: Name of contact person: Street address: State: Zip Code: Phone Number: Title of Contact Person: City: Fax Number: 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. Phone Internet Postal mailing In another State Other ___________________ Outstanding balance of all Wisconsin consumer credit transactions as of last December 31. $___________________ (If none, state "none.") Name of Designated Agent, if any: Street Address: State: Zip Code: Phone Number: City: Fax Number: Please sign Your Registration 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 Wisconsin Department of Financial Institutions. Printed Name: Authorized Signature: Title: Date: DFI/OCA/400A (R4/15) 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com . WISCONSIN CONSUMER ACT REGISTRATION INSTRUCTIONS Who Must File This Form 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. Thereafter you are required to submit a registration annually for each calendar year. We will mail you a registration form each January to be used in registering for the previous calendar year. (Exception: Future filing is required annually only if your yearend balance of consumer credit transactions for a calendar year is over $250,000.) Form 400A This form is to be used by first-time filers only. This form is also available at: www.wdfi.org/_resources/indexed/site/wca/business_guidance/registration/Reg Form-FirstTimeFilers20130103.pdf and can be made available in alternate formats upon request to qualifying individuals with disabilities. Information requested may be used for secondary purposes. 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. The original transaction must be $25,000 or less. This includes, but is not limited to: Student loans; 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; Checking account overdraft protection programs, if the money placed in the consumer's account must be repaid with interest. This does not include first mortgages. What is Considered a Consumer Credit Transaction Acknowledgement We will not provide an acknowledgment of your registration. Your cancelled check will serve as your acknowledgment. Mail registration form and payment to: Department of Financial Institutions PO Box 8041 Madison, WI 53708-8041 Telephone: (608) 264-7969 Fax: (608) 264-7968 www.wdfi.org DFI/OCA/400A (R4/15) 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com