A-771 — Disclosure Authorization (Third-Party Access)

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Employer: Name Phone Job Tit le / Position Gross Income Net Inc ome / month / month A-771 (R. 10-18) Request a Payment Plan Important Information about Payment Plans • A $20 fee will be added to your balance when a payment plan is accepted by the department • A payme nt plan will not preve nt the filing of a delin quent tax warra nt. A warra nt is a lien again st your prop erty and, as publ ic reco rd, may affec t your cred it ratin g. The filin g of a tax warr ant will add a fee to your bala nce. • Your Wisco nsin, feder al and other states ' tax refun ds, vendo r payme nts, uncla imed prope rty and lotter y winni ngs will be used to pay the amo unt due and will not be considered installment payments on your plan • All retu rns and taxe s must be filed and paid as they beco me due • T he depar tment reser ves the right to end any plan if we deter mine it was made based on false or incor rect infor mation, there is a signi ficant chan ge in your finan cial cond ition, or if you defa ult the term s of the plan • If you fail to make paym ents as agre ed or your plan is ende d, DOR will take coll ection acti ons allo wed by law with out furt her notic e • We will charg e you a colle ction fee on DOR tax debt equal to 6.5% of your amoun t due, with a minim um charg e of $35. The colle ction fee for state debt refe rred by anoth er agen cy is 15% of the amou nt due, with a mini mum char ge of $35. Part C: Your Spouse I am not married. Skip to Part D. General Assistance Wisco nsin Works Payments Socia l Security / SSI Other (list) Othe r (lis t) Othe r (lis t) Other Income: Employer: Name Phone Job Tit le / Position Gross Income Net Inc ome / month / month Other Income: General Assistance Wisco nsin Works Payments Socia l Security / SSI Other (list) Othe r (lis t) Othe r (lis t) Name Date of Birt h SSN Mailing Address Phone City State Zip Part B: Your Information Name Date of Birt h SSN Mailing Address Phone City State Zip Dependents: List names and ages Wisconsin Department of Revenue PO Box 8901 M adison WI 5370 8-8901 Phone: (608 ) 266- Fax: (608 ) 224- DORCompliance@wisconsin.gov Part A: Proposed Payment Plan Payment Amount Frequ ency First Paym ent Date Monthly Bi-weekly Weekly (must be 1-28 of the month) $ ( ) - ( ) - ( ) - ( ) -

Part E: Motor Vehicles, Boats, Motorcycles, Snowmobiles, ATV's, etc. (list all - attach separately if necessary) - 2 -A-771 (R. 10-18) Part D: Banks and Other Financial Institutions (list all - attach separately if necessary) Name Type (checking, savings, IRA, CD, money market, etc.) Balance Vehicle Year Make Mode l Vehicle Fair Market Value Bala nce Owe d Lien Hol der Year Mak e Mode l Fair Mar ket Val ue Balance Owe d Lien Hol der Part F: Real Estate (list all - attach separately if necessary) Location Fair Mar ket Val ue Mortgage Holder Bala nce Due Part G: Expenses 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 S pouse Sig nature Date Expense Note any payments that are behind and how muchMonthly Payment Total Balance Owed Mortgage (include escrow) or Rent Vehic le Payments Gasoline / Oil H ome Heat ing Electric Telephone Water Cable / Internet Loans (list) Cre dit Cards (list) Food: Insurance (all) : IRS - Del inquent Pay ment Entertainment/Other (attach list if needed) Utilities: Total Monthly Expenses Total N et Monthly Income Net Diff erence $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Upon receipt, the depa rtment will revi ew your requ est and dete rmine if addit ional info rmation or writ ten veri fication is requ ired. If so, you will be noti fied and give n a dead line to prov ide the addi tional docu mentation. Afte r all docu mentation is rec eived and rev iewed the dep artment wil l acce pt you r pro posal, iss ue a cou nter pro posal, or rej ect you r pro posal. N O T E