Form Pa 12510 - Questionnaire For Relief From Joint Liability For Requesting Spouse - State Of Pennsylvania
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4QUESTIONNAIRE FOR RELIEF FROM JOINT LIABILITY FOR REQUESTING SPOUSE
Form PA 12510
(Used in conjunction with Form PA 8857, Request for Relief from Joint Liability)
(10-09)
Your Name:
Your Social Security Number:
Purpose for this information
Depending on the nature of your claim for relief for joint liability, we must evaluate many factors including:
• Your marital status;
• Whether the items that created the liability are yours;
• Whether you believed that your spouse paid, or was going to pay, the tax due that you reported on your return;
• Your current financial situation; and
• Considering all the facts, is it fair to hold you responsible for the liability?
The Department recognizes that some of the questions below involve sensitive subjects; however, the Department needs this
information to evaluate the circumstances of your case and properly determine whether you qualify for relief.
Instructions
The questionnaire is divided into 5 parts. All parts may not apply to you. Please read the instructions for each part to see if it
applies to you. If so, answer all the questions for that part. 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 (understatement of tax, separation of liability or, income allocation relief).
1a. Are you crediting an overpayment to a prior year tax liability or the execution of a lien against your property
requesting a refund for any payment you made individually?
Yes
No
1b. Identify the date and amount of these payments. Provide any documentation you may have to prove you made these pay-
ments such as correspondence from the Department 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
Married, living apart
Provide date (month, day, year)
_____/_____/_____
Legally Separated
Provide date (month, day, year)
_____/_____/_____
Divorced
Provide date (month, day, year)
_____/_____/_____
Widowed
Provide date (month, day, year)
_____/_____/_____
(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(s) instead of your own separate return(s)?
4. What was your involvement in the preparation of the return(s)?
5. Did you review the tax return(s) before signing?
Yes
No
If no, explain why not.
Form PA 12510
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