Form 12510 - Questionnaire For Requesting Spouse Page 3
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411. On the date you signed the return or at the time you requested relief were you suffering from mental or physical health problems?
If yes, Please describe the nature and extent of your mental or physical health problem. Since we do not request
information of this nature from third parties, it is your responsibility to provide dates and any documentation such as
doctor statements or affidavits from someone aware of the problem.
12. What was your highest level of education during the year(s) you are requesting relief?
Note any business or tax related courses you completed by that time.
13. What was your (former) spouse's highest level of education during the year(s) you are requesting relief?
Note any business or tax related courses he or she completed by that time.
14. Have any assets been transferred from your (former) spouse to you?
[
] Yes
[
] No
If yes, list the assets and the date of transfer. Explain why they were transferred to you.
15. How was the money from the unpaid taxes spent?
16. Explain any other factors you feel should be considered for granting relief.
Part 2 – Complete this part if you are requesting relief for a balance due shown on your return when filed, but not paid.
[
] Yes
[
] No
1.
At the time you signed the return(s) did you know there was a balance due?
1a. If no, explain why you did not know.
1b. If yes, Who was responsible for paying the tax?
1c. Did you and your (former) spouse discuss when and how the underpayment would be paid?
2.
At the time you signed the return, did you know about any financial problems you and your (former) spouse were having such as a
bankruptcy, high credit card debt or difficulty in paying monthly living expenses?
[
] Yes
[
] No
If yes, please describe them.
3. After the return(s) was filed, what efforts were made by you and your (former) spouse to pay the tax?
Part 3 – Complete this part if you are requesting relief for additional tax as a result of an IRS examination.
1.
List all places of employment of your (former) spouse and the income received for the year(s) in question.
a.
$
b.
$
c.
$
d.
$
2. Was your (former) spouse self-employed?
[
] Yes
[
] No
If so, please indicate the type of self-employment.
12510
Catalog Number 28752D
Page 3 of 4
Form
(Rev. 3-2005)
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