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                     Wage Attachment Review Request                                               Wisconsin Department of Revenue
                                                                                                                PO Box 8901
                                                                                                       Madison WI  53708-8901
The Department will inform you if your proposed deduction amount is approved or if additional             Phone: (608) 266-7879
information is needed. If approved as proposed, your employer will be sent the updated deduc-             Fax: (608) 224-5790
tion amount. If it is determined that larger payments are necessary, or additional information is DORCompliance@wisconsin.gov
required, someone from the department will contact you. Be sure to complete both pages.
Tab to navigate within form. Use mouse to check applicable boxes, press spacebar or press Enter.
Part A:  Your Information
Name                                                              Date of Birth                        SSN

Mailing Address                                                   Phone
                                                                  ( )  -
City                                   State Zip

Dependents:  List names and ages

Employer:
Company Name                                                      Phone
                                                                  ( )  -
Mailing Address                                                   Job Title / Position

City                                   State Zip

Gross Income                           Net Income
                                /month                  /month
Other Income:
General Assistance                     Wisconsin Works Payments                 Social Security / SSI

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

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

Mailing Address                                                   Phone
                                                                  ( )  -
City                                   State Zip

Dependents:  List names and ages

Employer:
Company Name                                                      Phone
                                                                  ( )  -
Mailing Address                                                   Job Title / Position

City                                   State Zip

Gross Income                           Net Income
                                /month                  /month
Other Income:
General Assistance                     Wisconsin Works Payments                 Social Security / SSI

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

A-772 (R. 10-18)                                                                                                To Page 2

Part C:  Banks and Other Financial Institutions  (list all – attach separately if necessary)
                            Name                    Type (checking, savings, IRA, CD, money market, etc.)       Balance

Part D:  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 E:  Real Estate  (list all – attach separately if necessary)
Location                                                                                                    Fair Market Value
Mortgage Holder                                                                                             Balance Due

Part F:  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             REQUESTED DEDUCTION AMOUNT
Total Net Monthly Income                    $
                                                                     $                       Monthly
NetDifference                               $       0.00

Additional Information:
The       Department of Revenue may file delinquent tax warrants. These warrants are liens against your property and, as public records, may
affectyourcreditrating.     Thefilingofthesetaxwarrantswilladdadditionalchargestoyourbalance.
2.  Your Wisconsin tax refunds will be used to reduce the unpaid tax liability and will not be considered wage attachment payments on your agree-
ment.
Allreturnsandtaxesmustbefiledandpaidastheybecomedue.
4.  The Wisconsin Department of Revenue reserves the right to void any agreement if it is determined that it was made based on false or inac-
curateinformationorifthereisamaterialchangeinyourfinancialcondition.

Part G:  Signature
I/We attest that the information furnished on this form is true and correct to the best of my/our knowledge.
Taxpayer Signature                          Date                    Spouse Signature                        Date

A-772 (R. 10-18)                                         - 22       -
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