Form 12510 - Questionnaire For Requesting Spouse - 2004 Page 2
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45a. If no, explain why not.
5b. If no, did you ask your (ex) spouse or return preparer any questions?
Please list the questions you asked and who responded and the response.
6. During the year(s) in question did you have your own separate bank account(s)?
Yes
No
If yes, indicate the type of account(s).
Checking
Savings
Other
6a. What funds were deposited to the account(s)?
6b. What bills were paid out of the account(s)?
7. During the year(s) in question did you and your (ex)spouse have any joint bank account(s)?
Yes
No
If yes, indicate the type of account(s).
Checking
Savings
Other
7a. What access did you have to the account(s)?
(For example, were you able to make deposits, write checks and withdraw funds)?
7b. What funds were deposited to the account(s)?
7c. Who made the deposits?
7d. What bills were paid out of the account(s)?
7e. Who wrote the checks?
Yes
No
7f. Did you review the monthly bank statements?
7g. Did you balance the checkbook to the bank statements?
Yes
No
8. Did you pick up and open the household mail?
Yes
No
9. Were you abused by your (ex)spouce during year(s) in question? Please describe the nature an extent of the abuse.
Provide dates and any documentation such as police reports, doctor's statement or an affidavit from
someone aware of the abuse.
10. 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 extent of your mental or physical health problem. Please provide dates
and any documentation such as doctor statements or affidavits from someone aware of the problem.
12510
Catalog Number 28752D
Page 2 of 4
Form
(Rev. 1-2004)
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Parent category: Financial