Product Details

Name of Entity

Entity ID (if known)

How will Form 604 be submitted to DFI?

If "Other", specify

Date Form 604 will be submitted to DFI:

Additional Instructions

Contact Information

First Name

Last Name

Company Name

Address Line 1

Address Line 2

City

State/Province

Postal Code

Country

If "Other", specify

Phone Number

U.S. phone number
International phone number

Email Address

Repeat Email Address

Delivery Options*

U.S. Mail, sent to the Contact Information address

U.S. Mail, sent to another address

Pick up the order at Department of Financial Institutions, 4822 Madison Yards Way, North Tower, Madison WI 53705

Express/courier delivery service (at your expense)

Email, sent to the contact email address

Expedite this order.

There is an additional fee of $100.00 for expedited service.

Expedited service requests are acted upon by the close of business on the first business day following the date of receipt.

AMENDED STATEMENT OF QUALIFICATION - DOMESTIC LIMITED LIABILITY PARTNERSHIP - FORM 604