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Ss. 180.0860(1), 181.860(1) & 185.31(3) Wis. Stats.

State of Wisconsin Department of Financial Institutions Division of Corporate and Consumer Services

NEWLY ELECTED OFFICERS AND DIRECTORS
A. Name of the corporation: B. Principal officers were elected, or changes made on
Pursuant to such action, the principal officers are: (Append schedule if space is insufficient) TITLE
President/ Vice President/ Secretary/ Treasurer/

(Date).

NAME

BUSINESS ADDRESS (Complete mailing address)

C. Directors were elected, or changes made on
TITLE
Director Director Director Director Director

(Date). BUSINESS ADDRESS (Complete mailing address)

Pursuant to such action, the directors are: (Append schedule if space is insufficient) NAME

D. Executed on
(Date) Title: ! President or other officer title (Signature)

! Secretary
(Printed name)

FILING FEE - $3.00 See instructions, suggestions and procedures on following page. DFI/CORP/20(R02/10/03) Use of this form is voluntary.

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NEWLY ELECTED OFFICERS AND DIRECTORS (Chs. 180, 181 and 185)



Your return address and phone number during the day: (

) ______ - ___________________

INSTRUCTIONS (Ref. ss. 180.0860(1), 181.0860(1), 185.31(3) & 185.35(1), Wis. Stats. for document content) Submit one original and one exact copy to Dept. of Financial Institutions, P O Box 7846, Madison WI, 537077846, together with a FILING FEE of $3.00, payable to the department. Filing fee is non-refundable. (If sent by Express or Priority U.S. mail, address to 345 W. Washington Ave., 3rd Floor, Madison WI, 53703). The original must include an original manual signature, per sec. 181.0120(2), Wis. Stats. 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. A. Enter the name of the corporation or cooperative. (Note: This statement is not appropriate for use by limited partnerships, limited liability companies, or limited liability partnerships.) B & C. Enter the date new officers or directors were elected or appointed. Provide the name and address of all the principal officers and directors in office after giving effect to the elections or appointments. D. Enter the date of execution and the name and title of the person signing the document. The document must be signed by one of the following: An officer of the corporation (or incorporator if directors have not been elected), or a court-appointed receiver, trustee or fiduciary. A director is not empowered to sign. NOTE: Except as indicated below, the filing of this statement is optional. A corporation is not required to report changes in its officers or directors apart from the filing of its annual report. It may submit this statement for the public record to reflect changes occurring between the times it files its annual report. Whenever there is a change in officers or directors of a cooperative association, the association is obliged to report such change to the Department of Financial Institutions within 20 days. (See ss. 185.31(3) and 185.35(1), Wis. Stats.)

DFI/CORP/20I(R02/10/03)

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