Form A-771 - Request A Payment Plan Page 2
ADVERTISEMENT
1
2Part D: Banks and Other Financial Institutions
(list all – attach separately if necessary)
Name
Type
Balance
(checking, savings, IRA, CD, money market, etc.)
Part E: Motor Vehicles, Boats, Motorcycles, Snowmobiles, ATV’s, etc.
(list all – attach separately if necessary)
Year
Make
Model
Vehicle
Fair Market Value
Balance Owed
Lien Holder
1
Year
Make
Model
Vehicle
Fair Market Value
Balance Owed
Lien Holder
2
Part F: Real Estate
(list all – attach separately if necessary)
Location
Fair Market Value
Mortgage Holder
Balance Due
Part G: Expenses
Expense
Monthly Payment
Total Balance Owed
Note any payments that are behind and how much
Mortgage (include escrow) or Rent
$
$
Vehicle Payments
$
$
Gasoline / Oil
$
$
$
$
Home Heating
$
$
Electric
Utilities:
$
$
Telephone
Water
$
$
Cable / Internet
$
$
$
$
Loans (list)
$
$
$
$
$
$
Credit
$
$
Cards (list)
$
$
$
$
Food:
$
$
Insurance (all):
$
$
IRS – Delinquent Payment
$
$
Entertainment / Other (attach list if needed)
Total Monthly Expenses
$
Total Net Monthly Income
$
Net Difference
$
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
Spouse Signature
Date
N
Upon receipt, the department will review your request and determine if additional information or written verification is
O
required. If so, you will be notified and given a deadline to provide the additional documentation. After all documentation
T
is received and reviewed the department will accept your proposal, issue a counter proposal, or reject your proposal.
E
A-771 (R. 12-14)
- 2 -
revenue.wi.gov
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial