Form 12510 - Questionnaire For Requesting Spouse - 2004 Page 4
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43. 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 (ex)spouse about your concerns and what were you told?
3b. At the time you signed the return, how much did you know about each of the incorrect items?
3c. If no, when and how did you first become aware of the incorrect items?
4. If you received a refund 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.
This information is used to determine whether you qualify for equitable relief. To grant this relief we must
consider whether paying the tax liability would leave you unable to meet basic living expenses. We evaluate this
factor based on your current average monthly household income and expenses. Household includes a spouse or
another person living with you.
1. Please list the total number of adults and children in the household.
2. Please complete the following:
Average Monthly Household Income and Expenses
Amount
Income
Amount
Expenses
Wages
Rent or Mortgage
Pensions
Food
Unemployment
Utilities
Social Security
Telephone
State, Local and Federal Support
Auto Payments
Alimony
Auto Insurance
Auto - Gasoline & Repairs
Child Support
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
Social Security Number
Date signed
Daytime Phone number
Best time to call
For Privacy Act information, please refer to Notice 609 or Form 8857.
12510
Page 4 of 4
Form
(Rev. 1-2004)
Catalog Number 28752D
Department of the Treasury Internal Revenue Service
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