STATE OF WISCONSIN DEPARTMENT OF REVENUE
2135 RIMROCK ROAD PO BOX 8901 MADISON WI 53708-8901 Phone (608) 266-7879 FAX (608) 261-8978 delnqtax@revenue.wi.gov
Installment Agreement Request – Processing Fee Required
The department will inform you if your installment request is approved or if additional information is needed. If approved as proposed, an installment agreement will be forwarded to you. If it is determined that larger payments are necessary or additional information is required, someone from the department will contact you. Be sure to complete both sides of this form.
YOUR INFORMATION
Name
Social Security Number
Date of Birth
Address
City, State, Zip |
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Phone ( |
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Name(s) and ages of dependent(s)
Place of Employment
Company
Address
City, State, Zip |
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Phone ( |
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Job Title /Position |
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Gross Income |
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Net Income |
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Weekly |
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Bi-weekly |
Monthly |
Other Income |
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$ |
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General Assistance |
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$ |
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AFDC |
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$ |
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Social Security /SSI |
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$ |
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Other (specify) |
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$ |
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SPOUSE INFORMATION
Name
Social Security Number
Date of Birth
Address
City, State, Zip |
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Phone ( |
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Name(s) and ages of dependent(s)
Place of Employment
Company
Address
City, State, Zip |
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Phone ( |
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Job Title /Position |
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Gross Income |
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Net Income |
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Weekly |
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Bi-weekly |
Monthly |
Other Income |
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$ |
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General Assistance |
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$ |
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AFDC |
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$ |
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Social Security /SSI |
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$ |
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Other (specify) |
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$ |
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PROPOSED INSTALLMENT AGREEMENT
{ |
Monthly OR |
Semi-monthly |
Bi-weekly |
Weekly |
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Monthly Automatic Withdrawal |
(check withdrawal date) |
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First Payment / Withdrawal Date |
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INSTALLMENT AGREEMENT TERMS:
1.A $20.00 fee will be added to your balance when an installment agreement is accepted by the department.
2.An installment agreement will not prevent the iling of a delinquent tax warrant. These warrants are liens against your property and, as public records, may affect your credit rating. The iling of these tax warrants will add additional charges to your balance.
3.Your Wisconsin and Federal tax refunds will be used to reduce the unpaid tax liability and will not be considered installment payments on your agree- ment.
4.All returns and taxes must be iled and paid as they become due.
5.The Wisconsin Department of Revenue reserves the right to void any agreement if it is determined that it was made based on false or inaccurate infor- mation or if there is a material change in your inancial condition.
I/ We have read and understand the terms listed above and wish to enter into an installment agreement with the Wisconsin Department of Revenue. I/ We also attest that the information furnished on this form is true and correct to the best of my/our knowledge.
Please indicate both separate and combined assets and expenses.
Financial Institutions |
Balance |
Name and address of institution |
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Checking Account |
$ |
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Savings Account |
$ |
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Other (IRA, CD, |
$ |
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Money Market, etc.) |
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Life Insurance Policies |
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Cash |
Balance Due |
Company |
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Beneiciary |
Amount |
Value |
on Loan |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
No |
Have premiums been paid to date? |
Motor Vehicles |
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Make |
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Model |
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Year |
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Fair Market Value $ |
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Balance Due $ |
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License Plate # |
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Lien Holder |
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Address |
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Make |
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Model |
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Year |
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Fair Market Value $ |
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Balance Due $ |
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License Plate # |
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Lien Holder |
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Address |
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Other personal property (boat, motorcycle, snowmobile, etc.): |
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Real Estate (If you rent, list name and address of landlord) |
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Location |
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Fair Market Value $ |
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Balance Due $ |
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Mortgage Holder |
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Address |
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Expenses |
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Monthly |
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Please note any payments you |
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Payment |
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Balance Due |
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are behind in and by how much |
Mortgage or Rent |
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$ |
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$ |
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Property tax escrow |
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$ |
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$ |
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Auto payments |
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$ |
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$ |
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Gasoline/oil |
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$ |
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$ |
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Utilities: Home Heating |
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$ |
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$ |
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Electrical |
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$ |
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$ |
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Telephone |
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$ |
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$ |
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Water |
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$ |
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$ |
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Cable / internet access |
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$ |
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$ |
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Loans (list) |
1. |
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$ |
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$ |
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2. |
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$ |
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$ |
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3. |
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$ |
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$ |
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Credit Cards |
. . . . . . . . . Is card still in use? |
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VISA |
No |
Yes |
$ |
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$ |
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MasterCard |
No |
Yes |
$ |
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$ |
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Discover |
No |
Yes |
$ |
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$ |
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Other: |
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No |
Yes |
$ |
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$ |
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Food |
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$ |
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$ |
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Entertainment |
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$ |
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$ |
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Insurance (all) |
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$ |
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$ |
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IRS – Delinquent Payment |
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$ |
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$ |
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Other (list) |
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$ |
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$ |
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Total Monthly Expenses. . . . . . . . . . . . . . . . . . . .$
Total Net Monthly Income . . . . . . . . . . . . . . . . . .$
Net Difference . . . . . . . . . . . . . . . . . . . . . . . . . . .$