Fillable Wisconsin DOR - Form A772F Wage Attachment Review Request

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Wisconsin DOR - Form A772F Wage Attachment Review Request

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A-772 (R. 10-18)
The Department will inform you if your proposed deduction amount is approved or if additional
information is needed. If approved as proposed, your employer will be sent the updated deduc-
tion amount. If it is determined that larger payments are necessary, or additional information is
required, someone from the department will contact you. Be sure to complete both pages.
Wage Attachment Review Request
Wisconsin Department of Revenue
PO Box 8901
Madison WI 53708-8901
Phone: (608) 266-7879
Fax: (608) 224-5790
DORCompliance@wisconsin.gov
Employer:
Company Name Phone
Gross Income Net Income
/ month
/ month
Other Income:
General Assistance Wisconsin Works Payments Social Security / SSI
Other (list) Other (list) Other (list)
Part A: Your Information
Name Date of Birth SSN
Mailing Address Phone
City State Zip
Dependents: List names and ages
( ) -
( ) -
Mailing Address Job Title / Position
City State Zip
Employer:
Company Name Phone
Gross Income Net Income
/ month
/ month
Other Income:
General Assistance Wisconsin Works Payments Social Security / SSI
Other (list) Other (list) Other (list)
Part B: Your Spouse
Name Date of Birth SSN
Mailing Address Phone
City State Zip
Dependents: List names and ages
( ) -
( ) -
Mailing Address Job Title / Position
City State Zip
I am not married. Skip to Part C.
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A-772 (R. 10-18)
2- 2 -
Part C: Banks and Other Financial Institutions (list all – attach separately if necessary)
Name Type
(checking, savings, IRA, CD, money market, etc.)
Balance
Part G: Signature
Part E: Real Estate (list all – attach separately if necessary)
Location Fair Market Value
Mortgage Holder Balance Due
Part D: Motor Vehicles, Boats, Motorcycles, Snowmobiles, ATV’s, etc. (list all – attach separately if necessary)
Vehicle
1
Year Make Model
Vehicle
2
Fair Market Value Balance Owed Lien Holder
Year Make Model
Fair Market Value Balance Owed Lien Holder
I/We attest that the information furnished on this form is true and correct to the best of my/our knowledge.
Taxpayer Signature Date Spouse Signature Date
Additional Information:
1. TheDepartmentofRevenuemayledelinquenttaxwarrants.Thesewarrantsareliensagainstyourpropertyand,aspublicrecords,may
aectyourcreditrating.Thelingofthesetaxwarrantswilladdadditionalchargestoyourbalance.
2. Your Wisconsin tax refunds will be used to reduce the unpaid tax liability and will not be considered wage attachment payments on your agree-
ment.
3. Allreturnsandtaxesmustbeledandpaidastheybecomedue.
4. The Wisconsin Department of Revenue reserves the right to void any agreement if it is determined that it was made based on false or inac-
curateinformationorifthereisamaterialchangeinyournancialcondition.
Part F: Expenses
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
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
REQUESTED DEDUCTION AMOUNT
$
Monthly
0.00
0.00
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Wisconsin DOR - Form A772F Wage Attachment Review Request

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Completed 26 May 2020

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