TAB through to navigate. Use
Completed form can be submitted via email by clicking the
Email
Save
Print
Clear
mouse to check applicable boxes,
"Email" button, or it can be mailed or faxed to DOR using
press spacebar, or press Enter.
the contact information at the bottom of the page.
Wisconsin Tax Information Referral Form
INFORMATION ON INDIVIDUAL
INFORMATION ON BUSINESS
Person’s name
Business name
Street address
Street address
City
State
Zip
City
State
Zip
Social security number
Date of birth
Employer identification number
Occupation
What kind of business? (e.g., grocery store)
Marital status (check one)
Married
Single
Head of household
Divorced
Separated
Name of spouse, if applicable
1. Type of tax violation (check all that apply)
Income tax or withholding tax
Sales and use tax
Corporation franchise/ income tax
Other
2a. Amount of unreported income and tax years (fill in tax years and dollar amounts, if known; e.g., TY 2006, $20,000)
TAX YEAR
AMOUNT
TAX YEAR
AMOUNT
TAX YEAR
AMOUNT
TAX YEAR
AMOUNT
$
$
$
$
2b. Other type of tax violation, for example overstated expense, wrongly claimed dependent, ineligibility for certain credits,
etc. Describe in comments below.
Comments. Briefly describe who, what, where, when and how. (Attach 2nd page if more space is needed.)
3. Are books / records available?
Yes
No
4. Do you consider the taxpayer dangerous?
Yes
No
If yes, why?
5. Banks, financial institutions used by taxpayer:
Name
Name
Address
Address
City
State
Zip
City
State
Zip
6. Please describe how you learned and/or obtained the information in this report
(attach 2nd page if more space is needed):
7. If we have additional questions, can we contact you?
Yes
No
8. Do you want to remain anonymous?
Yes
No
Your name
Mail this form to: Wisconsin Department of Revenue
Audit Bureau, MS 5-144
Address
PO Box 8906
City
State
Zip
Madison WI 53708-8906
Telephone number (include area code)
Fax: 608-221-6637
Email Address
Questions about this form: Call 608-266-2772
P-626 (R. 5-16)
Wisconsin Department of Revenue
Go to Page 2