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                              Request a Payment Plan                                         WisconsinDepartmentofRevenue
                                                                                                      POBox8901
                                                                                                     MadisonWI 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
againstyourpropertyand,aspublicrecord,mayaffectyourcreditrating.Thefilingofataxwarrantwilladdafeetoyourbalance.
• YourWisconsin,federalandotherstates’taxrefunds,vendorpayments,unclaimedpropertyandlotterywinningswillbeusedtopay
the amount due and will not be considered installment payments on your plan
• Allreturnsandtaxesmustbefiledandpaidastheybecomedue
• The department reserves the right to end any plan if we determine it was made based on false or incorrect information, there is a
significantchangeinyourfinancialcondition,orifyoudefaultthetermsoftheplan
• Ifyoufailtomakepaymentsasagreedoryourplanisended,DORwilltakecollectionactionsallowedbylawwithoutfurthernotice
• WewillchargeyouacollectionfeeonDORtaxdebtequalto6.5%ofyouramountdue,withaminimumchargeof$35.Thecollection
feeforstatedebtreferredbyanotheragencyis15%oftheamountdue,withaminimumchargeof$35.
Click mouse in field or use tab to navigate througout form.
Part A:  Proposed Payment Plan
PaymentAmoun         Frequenc                                                                 FirstPaymentDate (must be 1‑28 of 
                                                                                                               the month)
$                           Monthly       Bi-weekly          Weekly

Part B:  Your Information
Nam                                                          DateofBirt                       SSN

MailingAddres                                                Phone
                                                             ( )  -
City                          State Zip

Dependents: Listnamesandages

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        Iamnotmarried. SkiptoPartD.
Nam                                                          DateofBirt                       SSN

MailingAddres                                                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     FairMarketValu            BalanceOwe                     LienHolder

        Year Make                                                Model
Vehicle
  2     FairMarketValu            BalanceOwe                     LienHolder

Part F:  Real Estate  (list all – attach separately if necessary)
Locatio                                                                                                FairMarketValue

MortgageHolde                                                                                          BalanceDue

Part G:  Expenses
                 Expense                    Monthly Payment Total Balance Owed Note any payments that are behind and how much
Mortgage(includeescrow)orRent               $               $
Vehicle Payments                            $               $
Gasoline/Oil                                $               $
                 HomeHeating                $               $
                 Electric                   $               $
Utilities:       Telephone                  $               $
                 Water                      $               $
                 Cable / Internet           $               $
                                            $               $
Loans(list)                                 $               $
                                            $               $
                                            $               $
Credit
Cards (list)                                $               $
                                            $               $
Food:                                       $               $
Insurance(all):                             $               $
IRS–DelinquentPayment                       $               $
Entertainment/Other (attach list if needed) $               $
TotalMonthlyExpenses                        $    0.00
Total Net Monthly Income                    $
NetDifference                               $    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.
YourSignatur                                Dat             SpouseSignatur                             Date

N   Upon receipt, the department will review your request and determine if additional information or written verification is
O   required. Ifso,youwillbenotifiedandgivenadeadlinetoprovidetheadditionaldocumentation. Afteralldocumentation
T
E   isreceivedandreviewedthedepartmentwillacceptyourproposal,issueacounterproposal,orrejectyourproposal.
A-771 (R. 10-18)                                      - 2 -
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