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Form S-127 - Assignment And Acknowledgement Of Notice Of Assignment - Wisconsin Department Of Revenue

ASSIGNMENT

Bank Acct. No.

Seller's Permit No.

(Real Name)

State

(Business Address)

Street

City

assigns to the Wisconsin Department of Revenue all rights and interest in the insured account or certificate

number

in the

Name of Financial Institution

in the amount

City

State

, which is delivered to the Wisconsin Department of Revenue herewith. The assignor retains

the right to income from the said account or certificate. Assignor agrees that this assignment includes the right in the

insurance of the account, by the Federal Deposit Insurance Corporation, the Federal Savings and Loan Insurance

Corporation or the Wisconsin Credit Union Savings Insurance Corporation and gives the Wisconsin Department of

Revenue the right to redeem, collect and withdraw the full amount of the account at any time with statutory notice

to the assignor. This assignment is given as security for the payment of sales and use taxes, including any interest

and penalties thereon. Assignor hereby notifies the above named institution of this assignment.

(Permit Holder or Authorized Person)

(Date)

ACKNOWLEDGEMENT OF NOTICE OF ASSIGNMENT

Assignment of the above account of certificate to the Wisconsin Department of Revenue is acknowledged. We

certify that we have received no notice of encumbrance or claim on the above account prior to this assignment. We

have noted in our records the department’s interest in this account as shown by the above assignment. We agree

to make payment under this assignment to the Wisconsin Department of Revenue upon request.

(Financial Institution)

(Date)

TITLE

(By)

Send original assignment plus one copy and certificate of deposit or passbook to the Wisconsin Department of

Revenue. Retain a copy for your financial institution records.

Questions regarding this assignment can be directed to Glenn Bille, Wisconsin Department of Revenue,

(608) 266-3120.

MAIL TO: Wisconsin Department of Revenue

PO Box 8902

Madison WI 53708-8902

S-127 (R. 4-97)

Form S-127 - Assignment And Acknowledgement Of Notice Of Assignment - Wisconsin Department Of Revenue