Employer’s Wage Attachment Remittance
                                                       Please reproduce this form and mail with future payments.

                                                                                                   Employer’s name
                        Applicable Laws and Rules
This document  provides  statements or interpretations  of  the following  laws  and               Payroll phone number
regulations enacted as of August 23, 2023: secs. 71.65 and 71.91(7), Wis. Stats.
                                                                                                   (      )                        -
Instructions.  Complete and send with your payment to the address below.  Use one line             Contact person name
for each employee from whom you have withheld delinquent taxes.  Do not include regular 
amounts of income taxes withheld.
Make checks payable to:          Wisconsin Department of Revenue                                        If payroll address has changed, enter new address below.
Mail remittance with this form to:  Wisconsin Department of Revenue                                Address
                                 PO Box 8960
                                 Madison WI  53708-8960
                                                                                                   City                                                  State            Zip
TERMINATED EMPLOYEE:  You are required to withhold the entire amount payable to 
terminated employees or an amount equal to the balance of certification.

Entry Required for Each Employee that had Delinquent Amounts Withheld This Period                  Check ONLY     Entry required if it applies to an employee under a wage certification.
                                                                                                     if this is                     Check whichever applies and enter the requested dates.
                                                                                                   the FINAL 
                                                       Employee’s                       Delinquent Payment of                                                                              Anticipated
                 Name of Employee                      Social Security                  Amount     the Wage                        Quit Last Day of Work                                   Return Date
                                                                                                                                                                   Lay-Off
                                                       Number                           Withheld   Attachment          Terminated/                       Temporary        Leave of Absence (month - year)

TOTAL AMOUNT WITHHELD   ......................................                 $
W-118a (R. 08-23)