State of Wisconsin
Department of Administration
Division of Housing
DOA-5565 (R02/2014)
http://doa.state.wi.us/divisions/housing / Submit this report & payment, if applicable, to:
Wisconsin department of administration
P.O. Box 7869
Madison, WI 53707-7869
Interest-Bearing Common Trust Account Remittance Report / FOR THE PERIOD ENDED
Bank Name
Address
/ Contact Person:
Phone Number:
Email Address:

Do not remit if total amount is less than $10, as stated in s. 452.13(2)(e)1, Wis. Stats.: “A depository institution is not required to remit any amount if the total interest or dividends for that period is less than $10 before any deduction for service charges or fees.”

BROKER NAME/ACCOUNT / INTEREST
RATE / ENDING BALANCE / INTEREST EARNED / SERVICE CHARGES / NET INTEREST
PAYABLE TO STATE
%
%
%
%
%
%
%
%
%
%
%
%
Totals: / $0.00 / $0.00 / $0.00 / $0.00

Completion of this form is required under ch. Adm 91, Wis. Adm. Code. DUE DATE: THIRTY DAYS AFTER THE REPORTING PERIOD.

The Department of Administration is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the Division of Housing at http://doa.state.wi.us/Divisions/Housing. PRIVACY NOTICE: Personal information you provide may be used for secondary purposes [s.15.04 (1)(m), Wis. Stats.].

This document can be made available in alternate formats to individuals with disabilities upon request.