Chapter 202, Wis. Stats.       STATE OF WISCONSIN                     Division of Corporate and 
                                                             Subchapter II                                                  Consumer Services,  
                                                                                    Department of Financial Institutions    Charities Section 

                                                                                                                            Mailing Address: 
                                                              E-Mail:                                                       PO Box 7879 
                                                DFICharitableOrgs@dfi.wisconsin.gov 
                                                                                                                            Madison, WI 53707-7879 

                                                    Telephone: (608) 267-1711        WEBSITE:  DFI.WI.GOV 
                       Please - Do Not Staple                                                    #2252                      Courier Address: 
                                                                                                                            4822 Madison Yards Way 
                                                      Fax: (608) 267-6813            CONVICTIONS AND PENDING                North Tower 
                                                                                                 CHARGES                    Madison, WI 53705 

Purpose:                                         If you have been convicted of a crime or have criminal charges pending against you, complete this form and return it 
with your application.  This form should only be submitted with registration applications for charitable organizations, professional 
fundraisers, fundraising counsels, professional employer organizations and professional employer groups.     

1. Provide the following personal information.

                                              Last Name:                            First Name:                          MI Former/Maiden Name(s): 

                                              Street Address:                                                               P.O. Box: 

                                              City:                                              State:                     Zip: 

                                              Date of Birth:                                     Social Security Number: 

                                              Name of Charity, Fundraiser, or PEO: 

2. List all other names used.

3. List all felonies, misdemeanors, and other violations of federal, state or local law or municipal ordinance of which you have ever
   been convicted, in this state or any other, whether the conviction resulted from a plea of no contest or a guilty plea or verdict.
   For each, list the date and location of the conviction.  Please include all convictions that involved alcohol and or other drug use,
   including convictions for operating while intoxicated.  During the department’s review of the application for registration, you
   may be asked to submit the following:
                                              • copies of the police report or criminal complaint
                                              • criminal history report
                                              • judgment of conviction and sentencing
                                              • verification of compliance with all terms of each sentence, including chemical dependency assessments (if ordered by the
                                                court)
                                              • information pertaining to probation or parole requirements and compliance
                                              • personal statement describing each offense along with an explanation of the penalties imposed and verification that you
                                                completed all requirements.

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  4. List all felonies, misdemeanors, or other violations of federal, state or local law or municipal ordinance for which you have 
     been arrested and which are pending against you.  For each, list the date of arrest and location (city/state).  Submit a copy 
     of the police report/criminal complaint for each pending charge. 
              
  5. Provide any comments you wish to make regarding your convictions or pending charges.  Additional pages may be attached. 
              
    AFFIDAVIT 
   
  I state that I am the person referred to in this document and that all information which I provided above is true in every respect.  I 
  understand that false or forged statements made in this document in connection with my application for a credential, or failing to 
  provide relevant information, may be grounds for denial of the application, revocation of the credential granted to me, or criminal 
  prosecution.   
  
  ______________________________________________________________________________________                                                                  
  Applicant Signature                                                                                Date             
 
  SUBSCRIBED AND SWORN TO BEFORE ME                   
  THIS ________ DAY OF   _________________,________   
             
  ________________________________________________   
  (Notary Public)                                                                        
   
  My Commission Expires: ___________________________  
  
  RETURN MATERIALS TO:      Department of Financial Institutions, Division of Corporate and Consumer Services. 
   
  Mailing Address:                                 Street Address:                      
  PO Box 7879                                      4822 Madison Yards Way, North Tower  
  Madison, Wisconsin 53707-7879                    Madison, Wisconsin 53705 
  
  The Fair Employment Act (sections 111.31-111.395, Wis. Stats.) prohibits employment discrimination on the basis of conviction record or arrest 
  record unless the circumstances of the conviction or arrest substantially relate to the circumstances of the particular job or licensed activity.  The 
  information requested on this form will be used to determine whether your application should be granted, approved with limitations, or denied.  
  The information you provide on this form may be verified against criminal information records.  Omission of information on this form will be 
  considered a false statement on an application. 
  
  CRED2252 (Revised November 2022)                                                                                   Page  2of  3
   

This form is required under Section 202.12, Wisconsin Statutes.  Refusal to provide this information may result in the denial of this registration 
application.  Personally identifiable information on this form may be matched against tax information, outstanding child and family support data 
and law enforcement agencies.  Failure to complete this application completely and accurately may result in denial or revocation of registration, 
and any other penalties as provided by law.   
This document can be made available in alternate formats upon request to qualifying individuals with disabilities. 

                                              FREQUENTLY ASKED QUESTIONS 

1. If I was named in a trial but not convicted, do I need to report or submit anything?
   You might want to send in a court document stating either that the charges were dismissed or you were acquitted.  If
   you entered into a deferred prosecution agreement, you might want to submit a copy of the agreement and verification
   that you have complied with all terms and conditions of the agreement.

2. What do I do if records are no longer available due to the length of time passed since the conviction?
   If convictions are old or records are no longer available, please include a personal statement (as described below)
   describing each offense listed on the #2252 along with an explanation of the penalties imposed and verification that you
   completed all requirements.

3. Do I need to report or submit anything about minor traffic violations, i.e. a speeding ticket?
   There is no need to disclose minor traffic violations.

4. How can I find out if I am excluded from getting a license due to a conviction?
   Each profession is regulated by its respective statutes and rules.  Please refer to the respective statutes and rules of the
   profession for which you are applying to determine whether your conviction records are substantially related to the
   practice of the profession.  We are unable to determine prior to full review whether an applicant will or will not be
   issued a license based on the conviction records.

5. How long does it take to review these documents?
   The time period for conviction review varies depending on when all documentation is received and whether it needs to
   be reviewed by supervisory staff.

6. What needs to be in the personal statement?
   A personal statement should describe each offense listed on the #2252 along with an explanation of the penalties
   imposed and verification that you completed all requirements.  You might also include any information about changes
   in your life (since the time of your last conviction) that you would like the division to consider during the review.

7. Do I need to hire a lawyer?
   It is your decision as to whether you need to hire an attorney.  If you would like a legal opinion you might want to hire
   a private attorney as the Department of Financial Institutions does not provide legal advice to applicants.

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