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STATE OF WISCONSIN SPS Fiscal Plans PO Box 8602 Madison WI 53708-8602 Department of Safety and Professional Services Governor Scott Walker Secretary Dave Ross Payment Voucher Transaction ID provided by S B can be located on web scheduler confirmation notice. If you have not received an ID number S B staff will provide one when plans are received* Check Dollar Amount Payer Name Payer Business Name Payer Address Payer City State Zip Code Phone Plan Submitter Name If different from Payer 1. Mail your check and this completed form to Madison WI 53708-8602 2. Send a copy of this completed payment voucher form along with your plan submittal documents to the office that you select below. Plans submitted to circle or check one of the offices Hayward Madison S B 201 W Washington Ave rd 3 Floor 53703 PO Box 7162 SBD Holmen 10541N Ranch Rd Hayward WI 54843 Green Bay Holmen S B. 3824 N Creekside La Holmen WI 54636 Waukesha 2331 San Luis Pl 54304 141 NW Barstow St* th 4 Floor 53188-3789. If you have not received an ID number S B staff will provide one when plans are received* Check Dollar Amount Payer Name Payer Business Name Payer Address Payer City State Zip Code Phone Plan Submitter Name If different from Payer 1. Mail your check and this completed form to Madison WI 53708-8602 2. Send a copy of this completed payment voucher form along with your plan submittal documents to the office that you select below. Mail your check and this completed form to Madison WI 53708-8602 2. Send a copy of this completed payment voucher form along with your plan submittal documents to the office that you select below. Plans submitted to circle or check one of the offices Hayward Madison S B 201 W Washington Ave rd 3 Floor 53703 PO Box 7162 SBD Holmen 10541N Ranch Rd Hayward WI 54843 Green Bay Holmen S B. Plans submitted to circle or check one of the offices Hayward Madison S B 201 W Washington Ave rd 3 Floor 53703 PO Box 7162 SBD Holmen 10541N Ranch Rd Hayward WI 54843 Green Bay Holmen S B. 3824 N Creekside La Holmen WI 54636 Waukesha 2331 San Luis Pl 54304 141 NW Barstow St* th 4 Floor 53188-3789. If you have not received an ID number S B staff will provide one when plans are received* Check Dollar Amount Payer Name Payer Business Name Payer Address Payer City State Zip Code Phone Plan Submitter Name If different from Payer 1. Mail your check and this completed form to Madison WI 53708-8602 2. Send a copy of this completed payment voucher form along with your plan submittal documents to the office that you select below. Plans submitted to circle or check one of the offices Hayward Madison S B 201 W Washington Ave rd 3 Floor 53703 PO Box 7162 SBD Holmen 10541N Ranch Rd Hayward WI 54843 Green Bay Holmen S B. Mail your check and this completed form to Madison WI 53708-8602 2. Send a copy of this completed payment voucher form along with your plan submittal documents to the office that you select below. Plans submitted to circle or check one of the offices Hayward Madison S B 201 W Washington Ave rd 3 Floor 53703 PO Box 7162 SBD Holmen 10541N Ranch Rd Hayward WI 54843 Green Bay Holmen S B. 3824 N Creekside La Holmen WI 54636 Waukesha 2331 San Luis Pl 54304 141 NW Barstow St* th 4 Floor 53188-3789.

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