Form A 772 PDF Details

Understanding the intricacies of managing debts can be quite challenging, especially when it involves wage attachments. The A 772 form plays a crucial role in this process, acting as a bridge between you and the Wisconsin Department of Revenue. It's designed to review requests for adjusting the amount deducted from wages to pay off debts. Completing this form involves providing detailed personal and financial information, such as income, expenses, and assets. By submitting the A 772 form, you're asking for an evaluation of your proposed deduction amount. If additional information is required or if it's determined that higher payments are needed, the Department will get in touch. The form facilitates communication between your employer and the Department, ensuring that any updated deduction amount is properly implemented. Through a combination of personal diligence and transparent disclosure of financial circumstances, this process seeks to balance your ability to meet living expenses while fulfilling obligations. It underscores the importance of accuracy and completeness in reporting, as any agreement reached can be voided if based on inaccurate information or if significant changes in financial status occur. The formidable task of navigating through these financial obligations is made feasible with the structured support provided by the A 772 form.

QuestionAnswer
Form NameForm A 772
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesa772, wisconsin a772 form, wisconsin form a 772, a772 form

Form Preview Example

Wage Attachment Review Request

The Department will inform you if your proposed deduction amount is approved or if additional information is needed. If approved as proposed, your employer will be sent the updated deduc- tion amount. 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 pages.

Wisconsin Department of Revenue

PO Box 8901

Madison WI 53708-8901

Phone: (608) 266-7879

Fax: (608) 224-5790

DORCompliance@wisconsin.gov

Part A: Your Information

Name

 

 

 

 

 

 

Date of Birth

 

SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependents: List names and ages

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer:

 

 

 

 

 

 

 

 

 

 

 

 

 

Company Name

 

 

 

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

Job Title / Position

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gross Income

 

 

Net Income

 

 

 

 

 

 

 

 

/ month

 

 

 

/ month

 

 

 

 

Other Income:

 

 

 

 

 

 

 

 

 

 

 

 

General Assistance

 

 

 

 

Wisconsin Works Payments

 

Social Security / SSI

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (list)

 

 

 

 

Other (list)

 

Other (list)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part B: Your Spouse

 

I am not married. Skip to Part C.

 

 

 

Name

 

 

 

 

 

 

Date of Birth

 

SSN

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

-

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependents: List names and ages

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer:

 

 

 

 

 

 

 

 

 

 

 

 

Company Name

 

 

 

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

-

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

Job Title / Position

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

Gross Income

 

 

Net Income

 

 

 

 

 

 

 

 

/ month

 

 

 

/ month

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Income:

 

 

 

 

 

 

 

 

 

 

 

General Assistance

 

 

 

 

Wisconsin Works Payments

 

Social Security / SSI

 

 

 

 

 

 

 

 

 

 

 

Other (list)

 

 

 

 

Other (list)

 

Other (list)

 

 

 

 

 

 

 

 

 

 

 

A-772 (R. 10-18)

 

 

 

 

 

 

 

 

 

 

Part C: Banks and Other Financial Institutions

(list all – attach separately if necessary)

 

Name

Type (checking, savings, IRA, CD, money market, etc.)

Balance

 

 

 

 

 

 

 

 

 

Part D: Motor Vehicles, Boats, Motorcycles, Snowmobiles, ATV’s, etc. (list all – attach separately if necessary)

 

Year

Make

Model

Vehicle

 

 

 

1

Fair Market Value

Balance Owed

Lien Holder

 

 

 

 

 

Year

Make

Model

Vehicle

 

 

 

2

 

 

 

Fair Market Value

Balance Owed

Lien Holder

 

 

 

 

Part E: Real Estate

(list all – attach separately if necessary)

Location

 

Fair Market Value

 

 

 

Mortgage Holder

 

Balance Due

 

 

 

Part F: 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

$

REQUESTED DEDUCTION AMOUNT

Total Net Monthly Income

$

$

 

 

Monthly

 

 

 

 

 

Net Difference

 

$

 

 

 

 

 

Additional Information:

1.The Department of Revenue may file delinquent tax warrants. These warrants are liens against your property and, as public records, may affect your credit rating. The filing of these tax warrants will add additional charges to your balance.

2.Your Wisconsin tax refunds will be used to reduce the unpaid tax liability and will not be considered wage attachment payments on your agree- ment.

3.All returns and taxes must be filed and paid as they become due.

4.The Wisconsin Department of Revenue reserves the right to void any agreement if it is determined that it was made based on false or inac- curate information or if there is a material change in your financial condition.

Part G: Signature

I/We attest that the information furnished on this form is true and correct to the best of my/our knowledge.

Taxpayer Signature

Date

Spouse Signature

Date

A-772 (R. 10-18)

- 2 -

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1. For starters, when filling out the wi review request form, begin with the page containing subsequent fields:

Find out how to prepare wi review form portion 1

2. After this segment is finished, you'll want to include the essential details in Part B Your Spouse Name, I am not married Skip to Part C, Date of Birth, SSN, Mailing Address, City, State, Zip, Dependents List names and ages, Phone, Employer Company Name, Mailing Address, Phone Job Title Position, City, and State in order to go further.

Stage number 2 in filling in wi review form

3. Within this step, look at Name, Type checking savings IRA CD money, Balance, Part D Motor Vehicles Boats, Vehicle, Vehicle, Year, Make, Fair Market Value, Balance Owed, Year, Make, Fair Market Value, Balance Owed, and Model. All of these are required to be taken care of with greatest attention to detail.

Make, Balance, and Fair Market Value in wi review form

4. This next section requires some additional information. Ensure you complete all the necessary fields - Electric, Telephone, Water, Cable Internet, Utilities, Loans list, Credit Cards list, Food, Insurance all, IRS Delinquent Payment, Entertainment Other attach list, Total Monthly Expenses, Total Net Monthly Income Net, REQUESTED DEDUCTION AMOUNT, and Monthly - to proceed further in your process!

Filling in part 4 of wi review form

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5. As you near the last parts of your form, you'll notice just a few extra requirements that should be satisfied. Particularly, I We attest that the information, Taxpayer Signature, Date, Spouse Signature, Date, and A R should be filled out.

Writing part 5 in wi review form

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