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

Employer:
Name Phone Job Title / Position
Gross Income Net Income
/ 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 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.

Part C:  Your Spouse I am not married. Skip to Part D.
General Assistance Wisconsin Works Payments Social Security / SSI
Other (list) Other (list) Other (list)
Other Income:
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)
Name Date of Birth SSN
Mailing Address Phone
City State Zip
Part B:  Your Information
Name Date of Birth SSN
Mailing Address Phone
City State Zip
Dependents: List names and ages
Wisconsin Department of Revenue
PO Box 8901
Madison WI 53708-8901
Phone: (608) 266-7879
Fax: (608) 224-5790
DORCompliance@wisconsin.gov
Part A:  Proposed Payment Plan
Payment Amount Frequency First Payment Date
Monthly Bi-weekly Weekly
(must be 1-28 of the month)
$
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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)