Form 12510 - Questionnaire For Requesting Spouse - 2004
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4Questionnaire for Requesting Spouse
12510
Form
(January 2004)
(Used in conjunction with Form 8857, Request for Innocent Spouse Relief)
Tax Year
Social Security Number
Name
Why we are requesting this information
Depending on the nature of your claim we must evaluate many factors.
We recognize that some of the questions below involve sensitive subjects. However, we need this information to evaluate
the circumstances of your case and properly determine whether you qualify for relief. If this form is not completed and
returned your claim may be denied.
Instructions
The questionnaire is divided into 4 parts.
• Parts 1 must be completed by everyone seeking relief.
• Parts 2 and 4 must be completed by everyone relief from a balance due shown on your return when filled, but not
paid.
• Part 3 must be completed and it is recommended that you complete Part 4 if you are seeking relief from a tax
liability that was determined as a result of an examination of the joint return.
Please answer all the questions for those parts that must be completed. If more space is needed you may attach additional
pages. Attach any documents you have that support your answers.
Part 1 – Complete this part for all requests for relief
1a. Are you requesting a refund of any payments you individually made?
Yes
No
1b. Payments you made include the IRS taking your refund from a later tax year or an IRS levy on your paycheck or
bank account. If so, identify the date and amount of these payments. Provide any documentation you have to prove
you made these payments such as correspondence from the IRS and copies of the front and back of cancelled
checks or money orders.)
2. What is the current marital status between you and the (ex)spouse with whom you filed the joint return(s) for the
year(s) you are requesting relief:
Married and living together
Provide date (month, day, year)
/
/
Married living apart
Provide date (month, day, year)
/
/
Legally Separated
Divorced
Provide date (month, day, year)
/
/
Provide date (month, day, year)
/
/
Widowed
(Enclose a complete copy of the separation agreement, divorce decree or death certificate. If you are still
married but living apart, provide documentation to verify the date of your separation such as copies of your
lease agreement or utility bills in your individual name.
3. Why did you file a joint return instead of your own separate return?
4. What was your involvement in the preparation of the return(s)? For example, did you gather the receipts and cancelled
checks, just provide your W-2's etc?
5. Did you review the tax return(s) before signing?
Yes
No
12510
Catalog Number 28752D
Page 1 of 4
Form
(Rev. 1-2004)
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