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Wisconsin Department of Revenue
PO Box 8901
Madison WI  53708-8901

Important Information about Payment Plans• A $20 fee will be added to your balance when a payment plan is accepted by the department

Phone: (608) 266-7879
Fax: (608) 224-5790
DORCompliance@wisconsin.gov• A payment plan will not prevent the filing of a delinquent tax warrant. A warrant is a lien
against your property and, as public record, may affect your credit rating. The filing 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 filed 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 asignificant change in your financial 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.

Click mouse in field or use tab to navigate throughout form.

Part A:  Proposed Payment Plan
Payment AmountFrequency$First Payment Date (must be 1‑28 ofMonthly

Bi-weeklythe month)WeeklyPart B:  Your Information
Name

Date of Birth

Mailing Address

Phone(CityState)

SSN-

Zip

Dependents:  List names and ages

Employer:
NamePhone

Gross Income

Net Income(Job Title / Position)-/ month
Other Income:/ monthGeneral Assistance

Wisconsin Works Payments

Social Security / SSIOther (list)

Other (list)

Other (list)

Part C:  Your SpouseName

I am not married.  Skip to Part D.

Mailing Address

Date of Birth
Phone(CityState)-Zip

Employer:
Name

Phone

Gross Income

Net Income(Job Title / Position)-/ month
Other Income:SSN/ month

General Assistance

Wisconsin Works Payments

Social Security / SSIOther (list)

Other (list)

Other (list)

A-771 (R. 10-18)

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Part D:  Banks and Other Financial Institutions (list all – attach separately if necessary)
Name

Type (checking, savings, IRA, CD, money market, etc.)

Balance

Part E:  Motor Vehicles, Boats, Motorcycles, Snowmobiles, ATV’s, etc. (list all – attach separately if necessary)
Vehicle1Vehicle

2Year

Make

Model

Fair Market Value

Balance Owed

Lien Holder

YearMake

Model

Fair Market Value

Balance Owed

Lien Holder

Part F:  Real Estate (list all – attach separately if necessary)
LocationFair Market Value

Mortgage Holder

Balance DuePart G:  Expenses
ExpenseMonthly Payment

Total Balance Owed Note any payments that are behind and how much

Mortgage (include escrow) or Rent$$

Vehicle Payments$$

Gasoline / Oil$$Home Heating$$

Electric$$

Telephone

$

$

Water

$

$

Cable / Internet

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Food:

$

$

Insurance (all):$$IRS – Delinquent Payment$$

Entertainment / Other (attach list if needed) $$Utilities:

Loans (list)

CreditCards (list)

Total Monthly Expenses$Total Net Monthly Income$Net Difference

$0.00

0.00

Part H:  Signature
I have read and understand the terms of a payment plan listed above. I have completed all information requested and attachedadditional pages if more room was needed. The information provided above is true and correct to the best of my knowledge.
Your Signature

NO
T
E

Date

Spouse Signature

Date

Upon receipt, the department will review your request and determine if additional information or written verification isrequired.  If so, you will be notified and given a deadline to provide the additional documentation.  After all documentationis received and reviewed the department will accept your proposal, issue a counter proposal, or reject your proposal.

A-771 (R. 10-18)-2-

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