Schedule                                   Sale of Investment in a
                    QI                    Qualified Wisconsin Business
             Wisconsin                                                                                                     2024
 Department of Revenue                       Include with Wisconsin Form 1 or 1NPR
 Name(s) shown on Form 1 or 1NPR                                                                                           Your social security number

Read instructions before filling in this schedule.

      1 Date investment sold
                                 m   m    d     d  y   y      y                    y

      2 Purchase date of the initial investment in the qualified Wisconsin business
        (The date must be after 12-31-2010, see Line 2 instructions.)                         m m         d             d  y y y y
      3 Type of investment   (check one)        Stock purchase                      Partnership interest                   LLC membership
        (If the investment was in a single member LLC, see General Instructions.)

      4 Fill in the name and FEIN of the qualified Wisconsin business. (Do NOT enter the broker’s information.)
      Entity name 
      FEIN

 4a   If a pass-through entity sold the investment, fill in the name and FEIN of the pass-through entity.
        (See Line 4a instructions.)
      Entity name
      FEIN

    5Sales price of investment as reported on federal Form 8949  ....................                                   5         .00

    6Cost or other basis adjusted for Wisconsin.
    (Wisconsin basis must be reduced for deferred long-term gain, see Line 6 instructions.)                             6         .00

    7Deferred long-term gain included in the investment   .............................                                 7         .00

    8Add line 6 and line 7  ...................................................                                         8         .00

    9Subtract line 8 from line 5  ...............................................                                       9         .00

 Non-Taxable Long-Term Gain
    10Amount you computed to be non-taxable qualified gain.  (See                   Line 10 instructions.)
        (Enter on line 15a of Schedule WD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10        .00

 Taxable Long-Term Gain
    11Add line 6 and line 10  ..................................................                                        11        .00

    12Net taxable long-term gain or (loss).  Subtract line 11 from line 5  .................                            12        .00

                       DRAFT 08-01-2024

I-077 (R. 7-24)