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                                Request a Payment Plan                                       Wisconsin Department of Revenue
                                                                                                            PO Box 8901
                                                                                                           Madison WI  53708-8901
Important Information about Payment Plans                                                                   Phone: (608) 266-7879
                                                                                                            Fax: (608) 224-5790
• A $20 fee will be added to your balance when a payment plan is accepted by the department
                                                                                             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 a
significant 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 Amount       Frequency                                                                      First Payment Date (must be 1‑28 of 
                                                                                                                       the month)
$                               Monthly       Bi-weekly           Weekly

Part B:  Your Information
Name                                                              Date of Birth                     SSN

Mailing Address                                                   Phone
                                                                  (        )           -
City                            State   Zip

Dependents:  List names and ages

Employer:
Name                                    Phone                                          Job Title / Position
                                        (            )      -
Gross Income                            Net Income
                                / month                                    / month
Other Income:
General Assistance                      Wisconsin Works Payments                       Social Security / SSI

Other (list)                            Other (list)                                   Other (list) 

Part C:  Your Spouse            I am not married.  Skip to Part D.
Name                                                              Date of Birth                     SSN

Mailing Address                                                   Phone
                                                                  (        )           -
City                            State   Zip

Employer:
Name                                    Phone                                          Job Title / Position
                                        (            )      -
Gross Income                            Net Income
                                / month                                    / month
Other Income:
General Assistance                      Wisconsin Works Payments                       Social Security / SSI

Other (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)
         Year                     Make                           Model
Vehicle
  1      Fair Market Value        Balance Owed                   Lien Holder

         Year                     Make                           Model
Vehicle
  2      Fair Market Value        Balance Owed                   Lien Holder

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

Mortgage Holder                                                                                         Balance Due

Part G:  Expenses
                 Expense                     Monthly 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                    $               $
Utilities:       Telephone                   $               $
                 Water                       $               $
                 Cable / Internet            $               $
                                             $               $
Loans (list)                                 $               $
                                             $               $
                                             $               $
Credit
Cards (list)                                 $               $
                                             $               $
Food:                                        $               $
Insurance (all):                             $               $
IRS – Delinquent Payment                     $               $
Entertainment /Other (attach list if needed) $               $
Total Monthly Expenses                       $    0.00
Total Net Monthly Income                     $
Net Difference                               $    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 attached 
additional pages if more room was needed.  The information provided above is true and correct to the best of my knowledge.
Your Signature                               Date            Spouse Signature                           Date

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