Form A-771 - Request A Payment Plan
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1
2Request a Payment Plan
Wisconsin Department of Revenue
PO Box 8901
Madison WI 53708-8901
Phone: (608) 266-7879
Important Information about Payment Plans
Fax: (608) 261-8978
• A $20.00 fee will be added to your balance when a payment plan is accepted by the
delnqtax@revenue.wi.gov
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 6½% of your amount due, with a minimum charge of $35.00. The
collection fee for state debt referred by another agency is 15% of the amount due, with a minimum charge of $35.00.
Part A: Proposed Payment Plan
Payment Amount
Frequency
First Payment Date
(must be 1‑28 of
the month)
$
Monthly
Bi-weekly
Weekly
Part B: Your Information
Name
Date of Birth
SSN
Mailing Address
Phone
(
)
City
State
Zip
Dependents: List names and ages
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)
Part C: Your Spouse
I am not married. Skip to Part D.
Name
Date of Birth
SSN
Mailing Address
Phone
(
)
City
State
Zip
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)
A-771 (R. 12-14)
revenue.wi.gov
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