Sec. 184.10 Wis. Stats.
State of Wisconsin Department of Financial Institutions Division of Corporate and Consumer Services
UNINCORPORATED NONPROFIT ASSOCIATION APPOINTMENT OF AGENT
1. Name of the unincorporated nonprofit association:
(Name must include the words "unincorporated association," "unincorporated assoc." or end with the abbreviation "U.A." or "UA".) 2. Address of the association:
(including street name and number, if any, city, state and ZIP code)
3. Name and address of the person in this state authorized to receive service of process on behalf of the association: Name: Address: (including street name and number, city in Wisconsin, and ZIP code)
4. The person named in this statement has accepted the appointment to act as agent to receive service of process on behalf of the association. 5. Check the box below if this statement amends a previously filed appointment of agent to receive service of process.
! This statement supersedes and takes the place of any original, amended or restated statement
previously filed. 6. Date: (Signature) Title: a person authorized to manage the affairs of the association. ,
See instructions, suggestions and procedures on following page. DFI/CORP/113-C(R2/10/03) Use of this form is mandatory. 1 of 2
FILING FEE - $15.00
UNINCORPORATED NONPROFIT ASSOCIATION APPOINTMENT OF AGENT (sec. 184.10, Wis. Stats.)
Your return address and phone number during the day: ( INSTRUCTIONS
) ______ - ____________
Submit statement to DEPARTMENT OF FINANCIAL INSTITUTIONS, Div. of Corporate & Consumer Services, P O Box 7846, Madison WI, 53707-7846, together with a $15 FILING FEE, payable to Dept. of Financial Institutions. Filing fee is non-refundable. If you want an acknowledgment copy of the filed statement, submit the document in duplicate and specify an address in the space above for its return. NOTICE: This form may be used to accomplish a filing required or permitted by statute to be made with the department. Information requested may be used for secondary purposes. If you have any questions, please contact the Division of Corporate & Consumer Services at 608-261-7577. Hearing-impaired may call 608-266-8818 for TDY. Sec. 184.10, Wis. Stats., provides that an unincorporated nonprofit association may appoint a person as agent to receive service of process by filing a statement with the Department of Financial Institutions, using the form prescribed by the department. 1. Enter the name of the unincorporated nonprofit association. 2. Provide the address of the association, including street and number, if any. The address may be in Wisconsin or elsewhere. 3. Provide the name and address of the person designated by the association to receive service of process on its behalf. The address must reflect the agent's physical location, i.e., street name, number, city in Wisconsin, and ZIP code. 4. This association must affirm that the registered agent has accepted the appointment to act as to receive service of process on behalf of the association. 5. If the statement is amending a statement previously filed, indicate that by marking (X) this item. 6. Enter the date the statement is signed, the title of the signer, and a signature. The statement is to be signed by a person who is authorized to manage the affairs of the unincorporated nonprofit association. This form is not appropriate for use by an incorporated association. If the association is incorporated, request and file "Change of Registered Agent and/or Registered Office" as provided by the statutory chapter under which it is organized. DFI/CORP113-CI(R2/10/03) 2 of 2