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Instructions for 2023 Schedule QI

Purpose of Schedule QI
Schedule QI is used to:
• Claim an exclusion for qualifying long-term capital gain from the sale of an investment in a qualified Wisconsin business.
• Adjust the gain or (loss) on the sale of an investment in a qualified Wisconsin business where the investor previously
deferred long-term capital gain that was invested in the qualified Wisconsin business.

Who May File Schedule QI
Schedule QI must be filed by individuals, including individual partners or members of a partnership, limited liability company,
limited liability partnership, or shareholders of a corporation, to claim the long-term capital gain exclusion.
Note A separate Schedule QI must be filed for each sale involving a qualified Wisconsin business that is eligible to exclude
long-term capital gain.
• If there are multiple sales of investments in the same qualified Wisconsin business, a separate Schedule QI must be filed for
each sale.
• If there are multiple investments involved in one sale of a qualified Wisconsin business, only file one Schedule QI to reflect
the entire sale. See example below.
Example On 8-30-2023, individual sells 900 shares of C corporation XYZ, 400 of the shares qualify for a long-term capital
gain exclusion. Of the 400 shares, 200 were purchased on 5-31-2018 and 200 on 6-30-2018. Even though there are two
qualified Wisconsin investments from 2018, there is only one sale occurring. Therefore, only one Schedule QI is filed for the
entire sale of the investment.

General Instructions
Exclusion of gain Certain long-term capital gains from the sale of an investment in a qualified Wisconsin business may be
excluded from income. The excludable long-term capital gain may not exceed the fair market value of the investment on the
date sold, less the fair market value of the investment on the date acquired.

Investment A qualified Wisconsin investment means:
• Amounts paid to acquire stock or other ownership interest in a partnership, corporation, tax-option (S) corporation, or limited
liability company treated as a partnership or corporation.
• The investment was in a business that was a qualified Wisconsin business for the year of the investment and at least two of
the four subsequent years, and
• The investment was made after December 31, 2010, and held for at least five uninterrupted years.

A qualified Wisconsin business means a business that was certified by the Wisconsin Economic Development Corporation or,
for 2014 and thereafter, was registered with the Department of Revenue. A list of qualified Wisconsin businesses is available
on our website at https://www.revenue.wi.gov/Pages/Report/qualified-businesses.aspx.
Caution As required by sec. 73.03(69)(d), Wis. Stats., businesses listed in this report have provided information concerning
property, payroll, and number of employees for purposes of registering as a qualified Wisconsin business. The information
has not been reviewed for purposes of determining eligibility for the exclusion or deferral.
Deferral of gain from a previous sale If you filed Wisconsin Schedule CG, Income Tax Deferral of Long-Term Capital Gain,
for 2011 or after, you may have qualified to defer tax on long-term capital gain if such gain was invested in a qualified Wisconsin
business.

The basis of the investment in the qualified Wisconsin business must be reduced by the amount of gain deferred. This deferred
gain is subject to tax when the investment is sold and it cannot be excluded.

Investment in a single member LLC If you invested in a single member LLC on or after January 1, 2011, the long-term
capital gain exclusion for investment in a qualified Wisconsin business may be allowed if both of the following are met:
• The LLC filed federal Form 8832 or 2553 electing to be taxed as a C corporation or S corporation on or before January 1,
2011, and the election was approved by the IRS.
• The federal election also applies for Wisconsin tax purposes.

I-177 (R. 11-23) Wisconsin Department of Revenue

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Specific Instructions
Line 1 Enter the date the investment in the qualified Wisconsin business was sold.

Line 2 Enter the date the first investment was made while the business was a qualified Wisconsin business. January 1, 2011,
was the first date available to invest in a qualified Wisconsin Business for purposes of the exclusion.

Note See example 1 under Sale of Investment in C Corporations later in these instructions. This example reflects shares
purchased as early as 5-31-2016; however, 5-31-2018 is the first date an investment was made when the C corporation was a
qualified Wisconsin business. Therefore, 05-31-2018 is entered on line 2 of Schedule QI.

Line 3 Only check one option for the entity structure of the qualified Wisconsin business.

Line 4 Enter the name and federal employer identification number (FEIN) of the qualified Wisconsin business. Do NOT enter
the broker’s information.

Line 4a If the exclusion you are claiming is a long-term capital gain received as pass-through income from a partnership, tax-
option (S) corporation, estate, or trust, enter the pass-through entity’s name and FEIN.

Line 5 Enter the sales price of the investment sold in the qualified Wisconsin business as reported on the federal Form 8949.

Line 6 The Wisconsin basis in the investment sold may differ from the federal basis. There may be a basis difference because:
• You deferred long-term capital gain from the sale of an asset on or after 2011 and invested the deferred gain in a qualified
Wisconsin business. This deferred gain is reported on Schedule CG for the year of the deferral.

You were a partner of a partnership or a shareholder of a tax-option (S) corporation and your annual adjustment to the basis
for Wisconsin tax purposes was more or less than the adjustment to the basis for federal tax purposes. This basis adjustment
is determined annually. See the Schedule 3K-1 instructions (partners) or the Schedule 5K-1 instructions (shareholders).

Note If you are affected by either or both of the above (or any other reason for difference in basis), you must complete Part 1 of
Wisconsin Schedule T, Transitional Adjustments, and line 6 or 15 of Wisconsin Schedule WD, Capital Gains and Losses. Also
enter the Wisconsin adjusted basis from Part 1 of Schedule T on line 6 of Schedule QI.

If the Wisconsin basis of your investment is the same as the federal basis, enter on line 6 of Schedule QI, the federal basis of
this investment as reported on federal Form 8949 or line 1a or 8a of Schedule D if Form 8949 is not filed.

Line 7 The amount of deferred long-term capital gain is the amount reported on Schedule CG for the appropriate year when
the qualified Wisconsin investment was made, and long-term capital gain was deferred on that investment.

Line 10 Report the gain entered on line 10 on line 15a of Schedule WD. Documentation showing how you computed the al-
location of the qualified gain must be filed with your return.

For C corporations, non-taxable qualified gain is directly related to the gain on shares sold from a qualified Wisconsin invest-
ment. See the examples under Sale of Investment in C Corporations below. For partnerships and tax-option (S) corporations
an allocation must be computed to determine the non-taxable qualified gain. See the examples under Sale of Investment in
Partnerships or Tax-Options (S) Corporations later in these instructions.

Note If line 9 is 0 (zero) or less, there can still be a non-taxable qualified gain, but only from the sale of an investment in a
C corporation.

Sale of Investment in C Corporations
If the sale of an investment in a C corporation includes investments made when the corporation was not a qualified Wisconsin
business, the investments must be separated to determine the taxable gain and non-taxable qualified gain. The non-taxable
qualified gain is directly related to the long-term capital gain on shares sold as a qualified Wisconsin investment.

Example 1
• C corporation XYZ was a qualified Wisconsin business for 2018, 2019, 2020, and 2021.

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•  900 Shares in C corporation XYZ were sold on 8-30-2023 at $100 per share as follows:

(The chart below reflects federal basis and has not been adjusted for Wisconsin)

                                                  Shares Sold                Selling Price               Basis of
Date of Purchase     Shares Purchased                                                                                            Gain/(Loss)
                                                  08-30-2023                             $100/Sh.  Shares Sold
    5-31-2016                200                    200                                  $20,000          $40,000                ($20,000)
    5-31-2017                200                    200                                  $20,000          $50,000                ($30,000)
    5-31-2018                200                    200                                  $20,000          $5,000                 $15,000
    6-30-2018                200                    200                                  $20,000          $5,000                 $15,000
    6-30-2019                100                    100                                  $10,000          $5,000                 $5,000
       Total                 900                    900                                  $90,000         $105,000                ($15,000)

•  Only the shares purchased on 5-31-2018 and 6-30-2018 are considered a qualified Wisconsin investment. 
  –  Shares in XYZ purchased in 2016 and 2017 do not qualify because XYZ was not a qualified Wisconsin business at the 
   time of the investment. 
  –  Shares purchased in 2019 do not qualify because the shares were not held for at least five years.
•  In this example investments made in XYZ did not include a deferred long-term capital gain from an asset previously sold. 
•  The capital gain of $30,000 ($15,000 + $15,000) on the sale of the 400 shares from 2018 is the non-taxable qualified long-
 term capital gain reported on line 10 of Schedule QI and must be reported on line 15a of Schedule WD. See example 2 below  
 on how to report a sale of investment when there is a deferred long-term capital gain. 
•  The sale of the investment is entered on Schedule QI as follows:
   Line 1    Date investment sold:    08  30  2023   
   Line 2    Purchase date of initial investment in the qualified Wisconsin business:  05   31  2018                   
   Line 3    Type of investment:         X  Stock purchase           Partnership interest                 LLC membership
   Line 4    Entity Name:                XYZ Inc.                            
             FEIN:    xx-xxxxxxx   
   Line 4a   If a pass-through entity sold the investment, fill in the name and FEIN of the pass-through entity.
             (See Line 4a instructions)
             Entity name
             FEIN
   Line 5    Sales price of investment as reported on federal Form 8949   ..................     90000              
   Line 6    Cost or other basis adjusted for Wisconsin  ................................   105000                  
   Line 7    Deferred long-term gain included in the investment   .........................                               0      
   Line 8    Add line 6 and line 7  .................................................   105000                      
   Line 9    Subtract line 8 from line 5  .............................................   - 15000                   

   Non-Taxable Long-Term Gain
   Line 10   Amount you computed to be non-taxable qualified gain.
           (Enter on line 15a of Schedule WD)      ......................................                               30000

   Taxable Long-Term Gain
   Line 11   Add line 6 and line 10   ................................................   135000                     
   Line 12   Net taxable long-term gain or (loss). Subtract line 11 from 5    ..................   - 45000          

 Example 2 (Deferred Gain) 
•  C corporation XYZ was a qualified Wisconsin business for 2018, 2019, 2020, and 2021.
•  The purchase of the 200 shares on 5-31-2018 included $5,000 of deferred long-term capital gain from an asset previously 
 sold. 

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•  900 Shares in C corporation XYZ were sold on 8-30-2023 at $100 per share as follows:

(The chart below reflects federal basis and has not been adjusted for Wisconsin)

                                                   Shares Sold                 Selling Price                 Basis of
Date of Purchase     Shares Purchased                                                                                      Gain/(Loss)
                                                   08-30-2023                  $100/Sh.              Shares Sold
     5-31-2016                 200                    200                                   $20,000          $40,000       ($20,000)
     5-31-2017                 200                    200                                   $20,000          $50,000       ($30,000)
     5-31-2018                 200                    200                                   $20,000          $5,000        $15,000
     6-30-2018                 200                    200                                   $20,000          $5,000        $15,000
     6-30-2019                 100                    100                                   $10,000          $5,000        $5,000
         Total                 900                    900                                   $90,000    $105,000            ($15,000)

•  Only the shares purchased on 5-31-2018 and 6-30-2018 are considered a qualified Wisconsin investment. 
  –  Shares in XYZ purchased in 2016 and 2017 do not qualify because XYZ was not a qualified Wisconsin business at the 
   time of the investment. 
  –  Shares purchased in 2019 are not a qualified Wisconsin investment because the shares were not held for at least five 
   years.
•  In this example the investment made on 5-31-2018 includes a $5,000 deferred long-term capital gain from an asset previously 
   sold. 
  –  The deferred long-term capital gain of $5,000 must be reported on Schedule T and Schedule WD. 
  –  The basis on line 6 of Schedule QI must be adjusted to reflect the $5,000 of deferred long-term capital gain. This will result 
   in a $100,000 basis ($105,000 - $5,000) on line 6 of Schedule QI. 
•  The capital gain of $30,000 ($15,000 + $15,000) on the sale of the 400 shares from 2018 is the non-taxable qualified long-
   term capital gain reported on line 10 of Schedule QI and must be reported on line 15a of Schedule WD. 
•  The sale of the investment is entered on Schedule QI as follows:
   Line 1      Date investment sold:    08  30  2023   
   Line 2      Purchase date of initial investment in the qualified Wisconsin business:  05   31  2018                  
   Line 3      Type of investment:        X  Stock purchase           Partnership interest                   LLC membership
   Line 4      Entity Name:                XYZ Inc.                            
               FEIN:    xx-xxxxxxx   
   Line 4a     If a pass-through entity sold the investment, fill in the name and FEIN of the pass-through entity.
               (See Line 4a instructions)
               Entity name
               FEIN
   Line 5      Sales price of investment as reported on federal Form 8949  ....................     90000              
   Line 6      Cost or other basis adjusted for Wisconsin  .................................   100000                  
   Line 7      Deferred long-term gain included in the investment  ...........................       5000              
   Line 8      Add line 6 and line 7   ..................................................   105000                     
   Line 9      Subtract line 8 from line 5   ..............................................   - 15000                  

    Non-taxable Long-Term Gain
   Line 10     Amount you computed to be non-taxable qualified gain.
               (Enter on line 15a of Schedule WD)      .....................................       30000

    Taxable Long-Term Gain
   Line 11     Add line 6 and line 10   .................................................   130000                     
   Line 12     Net taxable long-term gain or (loss). Subtract line 11 from 5  ....................   - 40000           

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 Sale of Investment in Partnerships or Tax-Option (S) Corporations
You must make a reasonable allocation of capital gain on the sale of the investment in a business that is not qualified for the 
entire investment period. The denominator is the fair market value (FMV) of all the investments you made in the entity and the 
numerator is only investments you made in the entity that are considered a qualified Wisconsin investment.

 Example 1
•  Partnership XYZ’s Partners A and B each have a 50% interest.
•  The partnership was a qualified Wisconsin business for 2018, 2019, 2020, and 2021. 
•  On 12-31-2023, Partner A liquidated its partnership interest in XYZ.

Investments Partner A made in XYZ and the capital gain from the sale of its partnership interest in XYZ are as follows:

(The chart below reflects federal basis and has not been adjusted for Wisconsin)

  Date of                      FMV of the Sales Price (FMV)                       Tax Basis of            Gain on Sale
  Investment                   Investment                12-31-2023               Investment   of Investment
  5-31-2016                    $  35,000
  5-31-2017                    $  20,000
  5-31-2018                    $  30,000
  12-31-2018                   $  50,000
  12-31-2019                   $  15,000
  12-31-2020                   $  10,000
  12-31-2021                   $  15,000
  12-15-2022                   $  25,000 
  Total                        $200,000                  $1,000,000                $100,000               $900,000

•  Only the investments made on 5-31-2018 and 12-31-2018 are considered a qualified Wisconsin investment.
  –  The business did not register with the Wisconsin Department of Revenue to be a qualified Wisconsin business in 2016, 
  2017, and 2022. Therefore, investments in XYZ made in 2016, 2017, and 2022 do not qualify.
  –  The investments made in 2019, 2020, and 2021 are not qualified Wisconsin investments because the investments were 
  not held at least five years.
•  In this example, investments made by Partner A in XYZ do not include a deferred long-term capital gain from an asset 
  previously sold.
•  The allocation percentage for non-taxable qualified gain is computed as follows:

  $  80,000 =  40%
  $200,000
  –  $80,000 reflects the FMV of qualified Wisconsin investments made in XYZ ($30,000 + $50,000) by Partner A on 5-31-2018 
  and 12-31-2018. 
  –  $200,000 reflects the FMV of the total investments made in XYZ by Partner A.
•  The non-taxable qualified gain is computed as follows:
  $800,000 x 40% = $320,000
  Although the capital gain on the sale of the investment is $900,000 ($1,000,000 - $100,000); the excludable long-term capi-
  tal gain may not exceed the fair market value of the investment on the date sold, less the fair market value of the investment 
  on the date acquired. Therefore, the amount used to compute the non-taxable qualified long-term capital gain is limited to 
  $800,000 ($1,000,000 - $200,000).
•  $320,000 is non-taxable qualified long-term capital gain reported on line 10 of Schedule QI and must be reported on line 15a 
  of Schedule WD. The net taxable long-term capital gain from the sale of the investment is $580,000. See example 2 below 
  for how to report a sale of investment when there is a deferred long-term gain. 

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• The sale of the investment is entered on Schedule QI as follows:
Line 1 Date investment sold: 12 31 2023
Line 2 Purchase date of initial investment in the qualified Wisconsin business: 05 31 2018
Line 3 Type of investment: Stock purchase X Partnership interest LLC membership
Line 4 Entity Name: XYZ LLC
FEIN: xx-xxxxxxx
Line 4a If a pass-through entity sold the investment, fill in the name and FEIN of the pass-through entity.
(See Line 4a instructions)
Entity name
FEIN
Line 5 Sales price of investment as reported on federal Form 8949 .................. 1000000
Line 6 Cost or other basis adjusted for Wisconsin ................................ 100000
Line 7 Deferred long-term gain included in the investment .......................... 0
Line 8 Add line 6 and line 7 ................................................. 100000
Line 9 Subtract line 8 from line 5 ............................................. 900000

Non-taxable Long-Term Gain
Line 10 Amount you computed to be non-taxable qualified gain.
(Enter on line 15a of Schedule WD) .................................... 320000

Taxable Long-Term Gain
Line 11 Add line 6 and line 10 ................................................ 420000
Line 12 Net taxable long-term gain or (loss). Subtract line 11 from 5 ................... 580000

Example 2 (Deferred Gain)
• Partnership XYZ’s Partners A and B each have a 50% interest.
• The partnership was a qualified Wisconsin business for 2018, 2019, 2020, and 2021.
• The investment made in XYZ on 5-31-2018 included $10,000 of deferred long-term capital gain from an asset previously sold.
• On 12-31-2023, Partner A liquidated its partnership interest in XYZ.

Investments Partner A made in XYZ and the capital gain from the sale of its partnership interest in XYZ are as follows:

(The chart below reflects federal basis and has not been adjusted for Wisconsin)

Date of FMV of the Sales Price (FMV) Tax Basis of Gain on Sale
Investment Investment 12-31-2023 Investment of Investment
5-31-2016 $ 35,000
5-31-2017 $ 20,000
5-31-2018 $ 30,000
12-31-2018 $ 50,000
12-31-2019 $ 15,000
12-31-2020 $ 10,000
12-31-2021 $ 15,000
12-15-2022 $ 25,000
Total $200,000 $1,000,000 $100,000 $900,000

• Only the investments made on 5-31-2018 and 12-31-2018 are considered a qualified Wisconsin investment.
– The business did not register with the Wisconsin Department of Revenue to be a qualified Wisconsin business in 2016,
2017, and 2022. Therefore, investments in XYZ made in 2016, 2017, and 2022 do not qualify.
– The investments made in 2019, 2020, and 2021 are not qualified Wisconsin investments because the investments were
not held at least five years.
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• In this example, the investment made on 5-31-2018 includes a $10,000 deferred long-term capital gain from an asset
previously sold.
– The deferred long-term capital gain of $10,000 must be reported on Schedule T and Schedule WD.
– The basis on line 6 of Schedule QI must be adjusted to reflect the $10,000 of deferred long-term capital gain. This results
in an $90,000 basis ($100,000 - $10,000) on line 6 of Schedule QI.
• The allocation percentage for non-taxable qualified gain is computed as follows:

$ 80,000 = 40%
$200,000
– $80,000 reflects the FMV of qualified Wisconsin investments made in XYZ ($30,000 + $50,000) by Partner A on 5-31-2018
and 12-31-2018.
– $200,000 reflects the FMV of the total investments made in XYZ by Partner A.
• The non-taxable qualified gain is computed as follows:
$800,000 x 40% = $320,000
Although the capital gain on the sale of the investment is $900,000 ($1,000,000 - $100,000); the excludable long-term capital
gain may not exceed the fair market value of the investment on the date sold, less the fair market value of the investment on the
date acquired. Therefore, the amount used to compute the non-taxable qualified long-term capital gain is limited to $800,000
($1,000,000 - $200,000).
• $320,000 is the non-taxable qualified long-term capital gain reported on line 10 of Schedule QI and must be reported on
line 15a of Schedule WD. The net taxable long-term capital gain from the sale of the investment is $590,000.
• The sale of the investment is entered on Schedule QI as follows:
Line 1 Date investment sold: 12 31 2023
Line 2 Purchase date of initial investment in the qualified Wisconsin business: 05 31 2018
Line 3 Type of investment: Stock purchase X Partnership interest LLC membership
Line 4 Entity Name: XYZ LLC
FEIN: xx-xxxxxxx
Line 4a If a pass-through entity sold the investment, fill in the name and FEIN of the pass-through entity.
(See Line 4a instructions)
Entity name
FEIN
Line 5 Sales price of investment as reported on federal Form 8949 .................. 1000000
Line 6 Cost or other basis adjusted for Wisconsin ................................ 90000
Line 7 Deferred long-term gain included in the investment ......................... 10000
Line 8 Add line 6 and line 7 ................................................. 100000
Line 9 Subtract line 8 from line 5 ............................................. 900000
Non-taxable Long-Term Gain
Line 10 Amount you computed to be non-taxable qualified gain.
(Enter on line 15a of Schedule WD) .................................... 320000
Taxable Long-Term Gain
Line 11 Add line 6 and line 10 ................................................ 410000
Line 12 Net taxable long-term gain or (loss). Subtract line 11 from 5 ................... 590000

Example 3 (Deferred Gain and Other Basis Adjustment)
• Partnership XYZ’s Partners A and B each have a 50% interest.
• The partnership was a qualified Wisconsin business for 2018, 2019, 2020, and 2021.
• The investment made in XYZ on 5-31-2018 included $10,000 of deferred long-term capital gain from an asset previously sold.
• The Wisconsin tax basis in the investment is $200,000 more than the federal basis due to depreciation differences.
• On 12-31-2023, Partner A liquidated its partnership interest in XYZ.

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Investments Partner A made in XYZ and the capital gain from the sale of its partnership interest in XYZ are as follows:

(The chart below reflects federal basis and has not been adjusted for Wisconsin)
  Date of                      FMV of the Sales Price (FMV)                     Tax Basis of          Gain on Sale
  Investment                   Investment                12-31-2023             Investment            of Investment
  5-31-2016                    $  35,000
  5-31-2017                    $  20,000
  5-31-2018                    $  30,000
  12-31-2018                   $  50,000
  12-31-2019                   $  15,000
  12-31-2020                   $  10,000
  12-31-2021                   $  15,000
  12-15-2022                   $  25,000 
  Total                        $200,000                  $1,000,000                $100,000           $900,000

•  Only the investments made on 5-31-2018 and 12-31-2018 are considered a qualified Wisconsin investment.
  –  The business did not register with the Wisconsin Department of Revenue to be a qualified Wisconsin business in 2016, 
  2017, and 2022. Therefore, investments in XYZ made in 2016, 2017, and 2022 do not qualify. 
  –  The investments made in 2019, 2020, and 2021 are not qualified Wisconsin investments because the investments were 
  not held at least five years.
•  In this example, the Wisconsin tax basis must be increased by $200,000 due to depreciation differences, and decreased 
  by $10,000 because the investment made on 5-31-2018 included a $10,000 deferred long-term capital gain from an asset 
  previously sold. 
  –  The $200,000 increase in Wisconsin tax basis and the $10,000 decrease in Wisconsin tax basis must be reported on 
  Schedule T and Schedule WD.
  –  The basis on line 6 of Schedule QI must be adjusted to reflect the $200,000 increase in Wisconsin tax basis and the 
  $10,000 decrease in Wisconsin tax basis. This results in a $290,000 basis ($100,000 + $200,000 - $10,000) on line 6 of 
  Schedule QI.
•  The allocation percentage for non-taxable qualified gain is computed as follows:

  $  80,000 =  40%
  $200,000
  –  $80,000 reflects the FMV of qualified Wisconsin investments made in XYZ ($30,000 + $50,000) by Partner A on 5-31-2018 
  and 12-31-2018. 
  –  $200,000 reflects the FMV of the total investments made in XYZ by Partner A.
•  The non-taxable qualified gain is computed as follows:
  –  $700,000 x 40% = $280,000
  –  $700,000 is the Wisconsin gain on the sale of the investment ($1,000,000 – ($100,000 +$200,000)). The amount does not 
  exceed the fair market value of the investment on the date sold, less the fair market value of the investment on the date ac-
  quired, $800,000 ($1,000,000 - $200,000). Therefore, the amount used to compute the non-taxable qualified long-term capital 
  gain is $700,000. 
  –  The $200,000 adjustment to increase Wisconsin tax basis for depreciation differences is recognized when computing the 
  gain used in the non-taxable qualified long-term capital gain allocation. 
  –  The $10,000 adjustment to decrease Wisconsin tax basis for deferred long-term capital gain is not recognized when com-
  puting the gain used in the non-taxable qualified long-term capital gain allocation. 
•  $280,000 is the non-taxable qualified long-term capital gain reported on line 10 of Schedule QI and must be reported on 
  line 15a of Schedule WD. The net taxable long-term capital gain from the sale of the investment is $430,000.

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• The sale of the investment is entered on Schedule QI as follows:
Line 1 Date investment sold: 12 31 2023
Line 2 Purchase date of initial investment in the qualified Wisconsin business: 05 31 2018
Line 3 Type of investment: Stock purchase X Partnership interest LLC membership
Line 4 Entity Name: XYZ LLC
FEIN: xx-xxxxxxx
Line 4a If a pass-through entity sold the investment, fill in the name and FEIN of the pass-through entity.
(See Line 4a instructions)
Entity name
FEIN
Line 5 Sales price of investment as reported on federal Form 8949 ................... 1000000
Line 6 Cost or other basis adjusted for Wisconsin ................................. 290000
Line 7 Deferred long-term gain included in the investment .......................... 10000
Line 8 Add line 6 and line 7 .................................................. 300000
Line 9 Subtract line 8 from line 5 .............................................. 700000
Non-taxable Long-Term Gain
Line 10 Amount you computed to be non-taxable qualified gain.
(Enter on line 15a of Schedule WD) ..................................... 280000
Taxable Long-Term Gain
Line 11 Add line 6 and line 10 ................................................. 570000
Line 12 Net taxable long-term gain or (loss). Subtract line 11 from 5 ................... 430000

Attachments
Include a complete copy of your federal income tax return with your Form 1 or 1NPR, a copy of Schedule QI, and an
explanation of how you computed the qualified gain.

Additional Information
For more information, you may:
Email your questions to: DORIncome@wisconsin.gov
Call: (608) 266-2772
Write to: MS 5-77
Wisconsin Department of Revenue
2135 Rimrock Road MS 5-77
PO Box 8949
Madison WI 53708-8949

Applicable Laws and Rules
This document provides statements or interpretations of the following laws and regulations enacted as of November 21,
2023: secs. 71.05(25) and (26), Wis. Stats.

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