State of Wisconsin DEPARTMENT OF FINANCIAL INSTITUTIONS Division of Corporate & Consumer Services DFI/CORP/521-A (/) Page 1 FILING FEE $40.00 OPTIONAL EXPEDITED + $25.00 SERVICE OFFICE USE ONLY FORM 521 - A Mandatory Foreign Limited Liability Company Application for Amended Certificate of Registration Chapter 183.1006 Wis. Stats. 1. Name of the Foreign Limited Liability Company under which you are currently registered in Wisconsin : 2. Legal name of the Foreign Limited Liability Company under which you are currently registered in your home jurisdiction : If the company222s name does not satisfy s. 183.0103(1) and (2) , Wis. Stats., the foreign limited liability company must obtain a certificate of registration to transact business in Wisconsin under a fictitious name that is available and that satisfies s. 183.0103(1) and (2) . (Enter Fictitious Name here if legal name is not available) 3. The name of the state or other jurisdiction under whose laws you are organized: If the state of organization has changed, please insert the previous jurisdiction here: 4. The date of organization: 5. Name of the registered agent in Wisconsin : 6 . Street address of the registered office in Wisconsin: (Ref. s. 183.1007 ) (Street Address) (City, State and Zip Code) 7 . Street address of office: (Required to be maintained in the state or other jurisdiction of the organization by the laws of that state or jurisdiction or, if no office is required, its principal office.) (Ref. s. 183.1004(6) ) (Street Address) (City, State and Zip Code) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 FORM 521 - A Page 2 8.Management of the Foreign Limited Liability Company is vested in one or more managers. Yes No 9.I certify that the applicant is a foreign limited liability company. Yes No 10. This document was executed on behalf of the Foreign limited liability companyon: (MM/DD/YYYY) (Print name of Individual who executed) Check one title: Manager Member Attorney-inFact (Signature of individual who executed) OPTIONAL 11. State the delayed effective date under s. 183.0111(2). This document has a delayed effective date of: (MM/DD/YYYY) 12.Contact information: (Name) (Address) (City) (State) ( Zip) (Phone Number ) (Email Address) Submit this form along with the non - refundable filing fee of to the address listed below. Make remittance payable to the Department of Financial Institutions . Optional expedited service: The non-refundable 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 . For answers to frequently asked questions, please see: Form 521 - A Instructions 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: Contact Information State of WI 226 Dept. of Financial Institutions Department of Financial Institutions Phone: 608 - 261 - 7577 Box 93348 Division of Corporate & Consumer Services Web: www.wdfi.org Milwaukee WI 53293 - 0348 201 W. Washington Ave 226 Suite 300 TTY: 711 Madison WI 53703 American LegalNet, Inc. www.FormsWorkFlow.com