Fillable Request a Payment Plan (Wisconsin)

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Request a Payment Plan (Wisconsin)

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The Request a Payment Plan (Wisconsin) form is 2 pages long and contains:

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File type: PDF

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Employer:
Name Phone Job Title / Position
Gross Income Net Income
/ month / month
A-771 (R. 10-18)
Request a Payment Plan
Important Information about Payment Plans
• A $20 fee will be added to your balance when a payment plan is accepted by the department
• Apaymentplanwillnotpreventthelingofadelinquenttaxwarrant.Awarrantisalien
againstyourpropertyand,aspublicrecord,mayaectyourcreditrating.Thelingofataxwarrantwilladdafeetoyourbalance.
• YourWisconsin,federalandotherstates’taxrefunds,vendorpayments,unclaimedpropertyandlotterywinningswillbeusedtopay
the amount due and will not be considered installment payments on your plan
• Allreturnsandtaxesmustbeledandpaidastheybecomedue
• Thedepartmentreservestherighttoendanyplanifwedetermineitwasmadebasedonfalseorincorrectinformation,thereisa
signicantchangeinyournancialcondition,orifyoudefaultthetermsoftheplan
• Ifyoufailtomakepaymentsasagreedoryourplanisended,DORwilltakecollectionactionsallowedbylawwithoutfurthernotice
• WewillchargeyouacollectionfeeonDORtaxdebtequalto6.5%ofyouramountdue,withaminimumchargeof$35.Thecollection
feeforstatedebtreferredbyanotheragencyis15%oftheamountdue,withaminimumchargeof$35.
Part C: Your Spouse
Iamnotmarried.SkiptoPartD.
General Assistance Wisconsin Works Payments Social Security / SSI
Other(list) Other(list) Other(list)
Other Income:
Employer:
Name Phone Job Title / Position
Gross Income Net Income
/ month / month
Other Income:
General Assistance Wisconsin Works Payments Social Security / SSI
Other(list) Other(list) Other(list)
Name DateofBirth SSN
MailingAddress Phone
City State Zip
Part B: Your Information
Name DateofBirth SSN
MailingAddress Phone
City State Zip
Dependents:Listnamesandages
WisconsinDepartmentofRevenue
POBox8901
MadisonWI53708-8901
Phone:(608)266-7879
Fax:(608)224-5790
DORCompliance@wisconsin.gov
Part A: Proposed Payment Plan
PaymentAmount Frequency FirstPaymentDate
Monthly Bi-weekly Weekly
(must be 1‑28 of
the month)
$
( ) -
( ) -
( ) -
( ) -
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Part E: Motor Vehicles, Boats, Motorcycles, Snowmobiles, ATV’s, etc. (list all – attach separately if necessary)
- 2 -
A-771 (R. 10-18)
Part D: Banks and Other Financial Institutions (list all – attach separately if necessary)
Name Type
(checking, savings, IRA, CD, money market, etc.)
Balance
Vehicle
1
Year Make Model
Vehicle
2
FairMarketValue BalanceOwed LienHolder
Year Make Model
FairMarketValue BalanceOwed LienHolder
Part F: Real Estate (list all – attach separately if necessary)
Location FairMarketValue
MortgageHolder BalanceDue
Part G: Expenses
Part H: Signature
I have read and understand the terms of a payment plan listed above. I have completed all information requested and attached
additional pages if more room was needed. The information provided above is true and correct to the best of my knowledge.
YourSignature Date SpouseSignature Date
Expense
Note any payments that are behind and how much
Monthly Payment Total Balance Owed
Mortgage(includeescrow)orRent
Vehicle Payments
Gasoline/Oil
HomeHeating
Electric
Telephone
Water
Cable / Internet
Loans(list)
Credit
Cards (list)
Food:
Insurance(all):
IRS–DelinquentPayment
Entertainment /Other
(attach list if needed)
Utilities:
TotalMonthlyExpenses
Total Net Monthly Income
NetDierence
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Uponreceipt,thedepartmentwillreviewyourrequestanddetermineifadditionalinformationorwrittenvericationis
required.Ifso,youwillbenotiedandgivenadeadlinetoprovidetheadditionaldocumentation.Afteralldocumentation
isreceivedandreviewedthedepartmentwillacceptyourproposal,issueacounterproposal,orrejectyourproposal.
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Request a Payment Plan (Wisconsin)

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Completed 18 December 2021

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