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
1g  Add lines 1a through 1f  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .            1g .00 .00 .00 1g                            .00

1hTotal  of line 1g from additional Forms 6Y (see instructions)Sample  . . . .  . 1h                          .00 .00 Form.00 1h                        .00
                             DRAFT 09-03-2024 
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