2024 Form 6Y - Wisconsin Modification for Dividends 
Designated Agent Name                                                                                                Federal Employer ID Number

                                         Corporation Name:
                                                                                                                                               Combined
                                                                FEIN:                                                                          Totals

   Name of Payer Corporation

1a Date Acquired by Payee     Payee's Ownership of Payer (check (√) one)

   M M          D D Y Y   Y Y > or = 70% > 50% but < 70%                                                  1a .00 .00 .00 1a                            .00
   Name of Payer Corporation

1b
   Date Acquired by Payee     Payee's Ownership of Payer (check (√) one)

   M M          D D Y Y   Y Y > or =70%  > 50% but < 70%                                                  1b .00 .00 .00 1b                            .00
   Name of Payer Corporation

1c Date Acquired by Payee     Payee's Ownership of Payer (check (√) one)

   M M          D D Y Y   Y Y > or = 70% > 50% but < 70%                                                     .00 .00 .00 1c                            .00
                                                                                                          1c
   Name of Payer Corporation

1d
   Date Acquired by Payee     Payee's Ownership of Payer (check (√) one)
   M M          D D Y Y   Y Y > or = 70% > 50% but < 70%
                                                                                                          1d .00 .00 .00 1d                            .00
   Name of Payer Corporation

1e
   Date Acquired by Payee     Payee's Ownership of Payer (check (√) one)
   M M          D D Y Y   Y Y > or = 70% > 50% but < 70%                                                  1e .00 .00 .00 1e                            .00
   Name of Payer Corporation

1f
   Date Acquired by Payee     Payee's Ownership of Payer (check (√) one)

   M M          D D Y Y   Y Y > or = 70% > 50% but < 70%                                                  1f .00 .00 .00 1f                            .00
                                         Sample Form 
1g Add lines 1a through 1f  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .            1g .00 .00 .00 1g                            .00
1h  Total of line 1g from additional Forms 6Y (see instructions)  . . . .  .                              1h .00 .00 .00 1h                            .00
2  Add lines 1g and 1h . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .           2  .00 .00 .00 2                             .00
3  Enter foreign taxes paid on dividends included on line 2   . . . . . .  .                              3  .00 .00 .00 3                             .00
4  Subtract line 3 from line 2 . Enter this amount on Form 6, Part II,
   line 4a  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .  4  .00 .00 .00 4                             .00
IC-425 (R. 8-24)
                                         File Electronically