Installment Agreement Request Form PDF Details

Navigating financial obligations can be daunting, especially when it involves managing tax dues. The Installment Agreement Request form serves as a lifeline for those seeking a structured plan to pay off their tax liabilities over time. By allowing taxpayers to propose a monthly, bi-weekly, or weekly payment plan, this form provides a semblance of flexibility and control over an otherwise stressful situation. However, it's important to note the associated $20 fee that adds to the balance once the plan is accepted. Despite the relief a payment plan might offer, it does not shield one from the filing of a delinquent tax warrant, which poses a threat to credit ratings due to its public record status. The form encompasses a comprehensive approach to understanding an applicant’s financial standing by requesting detailed information about income, expenses, assets, and liabilities. It emphasizes the significance of honesty and accuracy in reporting, as the Department of Revenue (DOR) holds the right to terminate any agreement if it's found to be based on false information, or if there's a considerable change in financial circumstances. The implications of failing to adhere to the agreed terms are clear—further collection actions without notice and an additional collection fee on the tax debt. Interestingly, the form also outlines how tax refunds, vendor payments, and even lottery winnings are funneiled toward the outstanding dues, underscoring the state’s commitment to recouping owed taxes. Through a blend of structure and strict conditions, the Installment Agreement Request form delineates a path towards financial steadiness while reinforcing the importance of fiscal responsibility.

QuestionAnswer
Form NameInstallment Agreement Request Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 771a form, wisconsin request payment plan, wi request payment form, wi payment plan online

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Request a Payment Plan

Important Information about Payment Plans

•A $20 fee will be added to your balance when a payment plan is accepted by the department

•A payment plan will not prevent the iling of a delinquent tax warrant. A warrant is a lien

Wisconsin Department of Revenue

PO Box 8901

Madison WI 53708-8901

Phone: (608) 266-7879

Fax: (608) 224-5790

DORCompliance@wisconsin.gov

against your property and, as public record, may afect your credit rating. The iling 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 iled 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 signiicant change in your inancial 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 6.5% of your amount due, with a minimum charge of $35. The collection fee for state debt referred by another agency is 15% of the amount due, with a minimum charge of $35.

Part A: Proposed Payment Plan

Payment Amount

Frequency

 

 

 

 

 

 

 

 

 

First Payment Date (MUST BE 1‑28 OF

$

 

 

 

 

 

Monthly

 

 

Bi-weekly

 

 

Weekly

 

 

THE MONTH)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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. 10-18)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part D: Banks and Other Financial Institutions

(list all – attach separately if necessary)

 

Name

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

Balance

 

 

 

 

 

 

 

 

 

Part E: 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 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 Diference

 

$

 

 

 

 

 

 

 

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 veriication is

O

required. If so, you will be notiied 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. 10-18)

- 2 -

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Tips on how to fill in a771a part 1

2. Soon after the first part is done, go to enter the relevant information in all these: Part C Your Spouse Name, Mailing Address, City, State, Zip, Date of Birth, SSN, Phone, Employer Name, Gross Income, Other Income General Assistance, Other list, A R, Phone Net Income, and Job Title Position.

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Lots of people frequently get some points incorrect while filling out Date of Birth in this section. Be certain to re-examine whatever you enter right here.

3. This next segment is about Name, Type checking savings IRA CD money, Balance, Part E Motor Vehicles Boats, Year, Make, Fair Market Value, Balance Owed, Year, Make, Fair Market Value, Balance Owed, Vehicle, Vehicle, and Model - complete each one of these blank fields.

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4. The next section will require your attention in the subsequent areas: Home Heating Electric, Telephone, Water, Cable Internet, Utilities, Loans list, Credit Cards list, and Food Insurance all IRS Delinquent. Ensure you provide all of the required details to move forward.

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5. This document should be finished with this section. Here one can find an extensive listing of fields that need to be filled out with accurate information to allow your form submission to be faultless: I have read and understand the, Spouse Signature, Date, Date, N O T E, Upon receipt the department will, and A R.

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