Application to Ascertain Wisconsin Net Income Tax                                                         SEND TO:
                                                                                        Wisconsin Department of Revenue
Reported As Paid or Payable                                                                          Central Audit Section, MS 5‑144
                                                                                                          PO Box 8906
Enclose fee of $4.00 for each income year requested.                                                 Madison WI 53708‑8906
                                                                                                     Telephone  (608) 266‑0945
Date                                                                                                      Fax  (608) 267‑0834

I,                                                     whose address is
                     (print or type name)                                               (street or RR No.)

                     (city or post office)                      (state)                 (zip code)
hereby make application to ascertain the Wisconsin income tax reported as paid or payable for the
year(s)                                                                                 of the following named taxpayer:

Taxpayer name

Taxpayer address
                                                       (include street, city and state)
Taxpayer business or occupation

If this information is obtained for any person other than the applicant or for any firm or corporation, state the name and 
address of that person, firm, or corporation.  (If none, write “None”)

Reason for request. This line must be completed. (N/A is not acceptable)

In making this application I hereby affirm and declare that I understand the provisions of sec. 71.78(2), Wis. Stats., relating 
to the divulgement, publication, or dissemination of information obtained from the above stated Wisconsin income tax return; 
that I am a resident of the state of                            , and that the information obtained is not for the use or 
benefit of nonresident person or firm, or a foreign corporation.

                                                       (signature of applicant)         (daytime telephone number)

Notary Public – Complete this section for mailed applications.
   State of                                )
                                               SS
County of                                  )
                                                                                                     IN WITNESS WHEREOF
On this the          day of                            , 20                     ,                    I hereunto set my hand
                                                                                                          and official seal.
before me,  
                             (print notary public name)
                                                                                                                  (SEAL)
the undersigned officer, personally appeared                                            ,
                                                                (print requestor’s name)
known to me (or satisfactorily proven) to be the person whose name is subscribed to the within
instrument and acknowledge that he/she executed the same for the purpose therein contained.

                (Notary Public Signature)
Notary Public Commission Expiration Date                        County                               State

Wisconsin Department of Revenue USE ONLY  (required information) – Employee instructions:
1.  For in‑person requests, attach a photocopy of requestor’s drivers license or other picture identification document to 
   this request form.
2.  Fee must be prepaid ($4 per return requested)  ...................... Amount collected  $

3.  Employee name                                                                       Received date
P‑100 (R. 1‑13)