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The Wisconsin Tax A 771 form is an essential document for individuals seeking to establish an installment agreement with the Wisconsin Department of Revenue. This form is particularly useful for those who find themselves unable to pay their tax liabilities in full and prefer to spread their payments over time. When filling out the form, taxpayers need to provide personal information, including their name, Social Security number, and details about their income and expenses. It’s important to complete both sides of the form accurately, as the Department of Revenue uses this information to assess the taxpayer's financial situation. The form outlines the terms of the installment agreement, including a processing fee and stipulations regarding the use of tax refunds to offset unpaid liabilities. Moreover, it highlights the potential consequences of not adhering to the agreement, such as the filing of delinquent tax warrants, which can affect credit ratings. Understanding these aspects can help taxpayers navigate their obligations more effectively and avoid additional financial strain.

Form Example

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

 

Phone (

)

Name(s) and ages of dependent(s)

Place of Employment

Company

Address

City, State, Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone (

)

 

 

 

 

 

 

 

 

 

 

 

 

Job Title /Position

 

 

 

 

 

 

 

 

 

 

Gross Income

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Net Income

 

 

 

Weekly

 

Bi-weekly

Monthly

Other Income

 

 

 

 

$

 

 

 

 

 

 

 

 

 

General Assistance

 

$

 

 

 

 

 

AFDC

 

 

 

 

$

 

 

Social Security /SSI

 

$

 

 

 

 

 

Other (specify)

 

 

 

 

$

 

 

 

 

 

 

 

 

SPOUSE INFORMATION

Name

Social Security Number

Date of Birth

Address

City, State, Zip

 

Phone (

)

Name(s) and ages of dependent(s)

Place of Employment

Company

Address

City, State, Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone (

)

 

 

 

 

 

 

 

 

 

 

 

 

Job Title /Position

 

 

 

 

 

 

 

 

 

 

Gross Income

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Net Income

 

 

 

Weekly

 

Bi-weekly

Monthly

Other Income

 

 

 

 

$

 

 

 

 

 

 

 

 

 

General Assistance

 

$

 

 

 

 

 

AFDC

 

 

 

 

$

 

 

Social Security /SSI

 

$

 

 

 

 

 

Other (specify)

 

 

 

 

$

 

 

 

 

 

 

 

 

PROPOSED INSTALLMENT AGREEMENT

$

/ /

(mo/day/yr)

{

Monthly OR

Semi-monthly

Bi-weekly

Weekly

 

Monthly Automatic Withdrawal

(check withdrawal date)

First Payment / Withdrawal Date

 

 

5th

15th

25th

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.

Your Signature

Date

Spouse Signature

Date

A-771 (R. 4-12)

Please indicate both separate and combined assets and expenses.

Financial Institutions

Balance

Name and address of institution

 

Checking Account

$

 

 

 

 

 

 

 

 

 

 

Savings Account

$

 

 

 

 

 

 

 

 

 

 

Other (IRA, CD,

$

 

 

 

 

 

 

 

 

 

 

Money Market, etc.)

 

 

 

 

 

 

 

 

 

 

 

Life Insurance Policies

 

 

 

 

 

 

 

 

Cash

Balance Due

Company

 

 

 

 

Beneiciary

Amount

Value

on Loan

 

 

 

 

 

 

 

$

 

$

 

$

 

 

 

 

 

 

 

$

 

$

 

$

 

 

 

 

 

 

 

$

 

$

 

$

Yes

No

Have premiums been paid to date?

Motor Vehicles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Make

 

 

 

 

 

 

Model

 

 

 

 

 

 

 

Year

 

 

Fair Market Value $

 

 

 

Balance Due $

 

License Plate #

 

 

 

 

 

Lien Holder

 

 

 

 

 

Address

 

 

 

 

 

Make

 

 

 

 

 

 

Model

 

 

 

 

 

 

 

Year

 

 

Fair Market Value $

 

 

 

Balance Due $

 

License Plate #

 

 

 

Lien Holder

 

 

 

 

 

Address

 

 

 

 

 

Other personal property (boat, motorcycle, snowmobile, etc.):

 

 

 

 

 

 

 

 

 

 

Real Estate (If you rent, list name and address of landlord)

 

 

 

 

 

 

 

 

 

 

Location

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fair Market Value $

 

 

 

Balance Due $

 

Mortgage Holder

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

Expenses

 

 

 

 

 

 

 

 

 

 

 

 

 

Monthly

 

 

 

 

 

 

 

Please note any payments you

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Payment

 

 

Balance Due

 

 

are behind in and by how much

Mortgage or Rent

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Property tax escrow

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Auto payments

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gasoline/oil

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Utilities: Home Heating

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Electrical

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

Telephone

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Water

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cable / internet access

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Loans (list)

1.

 

 

 

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Credit Cards

. . . . . . . . . Is card still in use?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VISA

No

Yes

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MasterCard

No

Yes

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Discover

No

Yes

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

No

Yes

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Food

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entertainment

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

Insurance (all)

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRS – Delinquent Payment

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (list)

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

Total Monthly Expenses. . . . . . . . . . . . . . . . . . . .$

Total Net Monthly Income . . . . . . . . . . . . . . . . . .$

Net Difference . . . . . . . . . . . . . . . . . . . . . . . . . . .$

Document Specs

Fact Name Details
Form Purpose The Wisconsin Tax A-771 form is used to request an installment agreement for paying delinquent taxes.
Processing Fee A processing fee of $20.00 is added to the balance when an installment agreement is accepted.
Approval Notification The Department of Revenue will notify you if your installment request is approved or if more information is needed.
Tax Warrants Entering an installment agreement does not prevent the filing of a delinquent tax warrant, which can affect your credit rating.
Tax Refunds Your Wisconsin and Federal tax refunds will be applied to your unpaid tax liability, not considered as installment payments.
Filing Requirements All tax returns and payments must be filed and paid as they become due to maintain the agreement.
Governing Laws This form is governed by Wisconsin Statutes, particularly those related to tax collection and installment agreements.
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