Form 12510 - Questionnaire For Requesting Spouse Page 4
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1
2
3
4[
] Yes
[
] No
2a. If your (former) spouse was self-employed, did you assist him/her with the business?
2b. If yes, what were your duties or responsibilities?
3.
At the time of signing the tax return(s), were you concerned about any item(s) omitted from or reported incorrectly on
the return(s)?
[
] Yes
[
] No
3a. If yes, did you inquire of your (former) spouse about your concerns and what were you told?
3b. If no, when and how did you first become aware of the incorrect item(s)?
3c. At the time you signed the return, how much did you know about each of the incorrect items?
(Example: the dollar amount, type of income, deduction, expense, credit, etc.)
4.
If a refund was due/issued when the return was filed, how was the money used?
Part 4 – Complete this part if you completed Part 2. Completing this part is optional if you completed Part 3.
However, doing so now may expedite consideration of your claim.
1.
Please list the total number of adults and children in the household.
2.
Please complete the following based on your current average monthly household income and expenses.
Household includes a spouse or another person living with you:
Current Average Monthly Household Income and Expenses
Income
Amount
Expenses
Amount
Wages
Rent or Mortgage
Pensions
Food
Unemployment
Utilities
Social Security
Telephone
State, Local and Federal Support
Auto Payments
Alimony
Auto Insurance
Child Support
Auto - Gasoline & Repairs
Self-Employment
Medical - Insurance & Other
Rental Income
Life Insurance
Interest and Dividends
Clothing
Other(Gov't Assistance, Food Stamps, etc)
Child Care
Public Transportation
Other (please explain)
Less deductions for W/H, Medicare, state
(
)
Taxes, etc
TOTAL
TOTAL
Under penalties of perjury, I declare that I have examined this statement and to the best of my knowledge it is true, correct, and
complete.
Signature
SSN
Date
Daytime Phone #
Best Time to Call
12510
Form
(Rev. 3-2005)
Department of the Treasury Internal Revenue Service
Catalog Number 28752D
Page 4 of 4
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