State of Wisconsin                                                                     DEPARTMENT OF REVENUE
                    2135 RIMROCK ROAD       PO BOX 8901       MADISON WI  53708-8901       Phone (608) 266-7879       FAX (608) 261-8978       delnqtax@revenue.wi.gov           

                                                   Wage Attachment Review Request
The Department will inform you if your proposed deduction amount is approved or if additional information is needed. If approved 
as proposed, your employer will be sent the updated deduction amount. If it is determined that larger payments are necessary 
or additional information is required, someone from the department will contact you. Be sure to complete both pages.

                   YOUR INFORMATION                                                                                                                                        SPOUSE INFORMATION
Name                                                                                                                              Name
Social Security Number                                                                                                            Social Security Number
Date of Birth                                                                                                                     Date of Birth
Address                                                                                                                           Address
City, State, Zip                                                                                                                  City, State, Zip
Phone  (         )                                                                                                                Phone  (                                )
Name(s) and ages of dependent(s)                                                                                                  Name(s) and ages of dependent(s)

Place of Employment                                                                                                               Place of Employment
Company                                                                                                                           Company
Address                                                                                                                           Address
City, State, Zip                                                                                                                  City, State, Zip
Phone  (         )                                                                                                                Phone  (                                )
Job Title/Position                                                                                                                Job Title/Position
Gross Income                                                                                                                      Gross Income
Net Income         Weekly                          Bi-weekly                                              Monthly                 Net Income                               Weekly    Bi-weekly     Monthly
                                               $                                                                                                                                    $
Other Income                                                                                                                      Other Income
General Assistance                             $                                                                                  General Assistance                                $
AFDC                                           $                                                                                  AFDC                                              $
Social Security/SSI                            $                                                                                  Social Security/SSI                               $
Other (specify)                                $                                                                                  Other (specify)                                   $

REQUESTED DEDUCTION AMOUNT

$                                Monthly

Additional Information:
1.  The Department of Revenue may file delinquent tax warrants. These warrants are liens against your property and, as public records, 
  may affect  your credit rating. The filing of these tax warrants will add additional charges to your balance.
2.  Your Wisconsin tax refunds will be used to reduce the unpaid tax liability and will not be considered wage assignment payments on 
  your agreement.
3.  All returns and taxes must be filed and paid as they become due.
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 
  inaccurate information or if there is a material change in your financial condition.

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

A-772 (R. 10-16)

                          Please indicate both separate and combined assets and expenses.
Financial Institutions         Balance                                    Name and address of institution
Checking Account         $
Savings Account          $
Other (IRA, CD,          $
Money Market, etc.)
Life Insurance Policies                                                                   Cash            Balance Due
                 Company                               Beneficiary          Amount        Value           on Loan
                                                                          $             $                $
                                                                          $             $                $
                                                                          $             $                $
Have premiums been paid to date?           Yes         No

Motor Vehicles
Make                     Model                         Year        Fair Market Value $    Balance Due $
License Plate #                Lien Holder                                Address
Make                     Model                         Year        Fair Market Value $    Balance Due $
License Plate #                Lien Holder                                Address
Other personal property (boat, motorcycle, snowmobile, etc.):

Real Estate (If you rent, list name and address of landlord)
Location                                                           Fair Market Value $    Balance Due $
Mortgage Holder                                                    Address

Expenses                                               Monthly                          Please note any payments you
                                                       Payment      Balance Due         are behind in and by how much
Mortgage or Rent                           $                       $
Property tax escrow                        $                       $
Auto payments                              $                       $
Gasoline/oil                               $                       $
Utilities:  Home Heating                   $                       $
      Electrical                           $                       $
      Telephone                            $                       $
      Water                                $                       $
      Cable / internet access              $                       $
Loans (list)  1.                           $                       $
             2.                            $                       $
             3.                            $                       $
Credit Cards  ....... Is card still in use?
 VISA  ...........       No      Yes       $                       $
 MasterCard ......       No      Yes       $                       $
 Discover  ........      No      Yes       $                       $
 Other:                  No      Yes       $                       $
Food                                       $                       $
Entertainment                              $                       $
Insurance (all)                            $                       $
IRS – Delinquent Payment                   $                       $
Other (list)                               $                       $
Total Monthly Expenses. . . . . . . . . . . . . . . . $
Total Net Monthly Income  .............. $
Net Difference ....................... $
A-772 (R. 10-16)                                                   2