Publication 971 - Innocent Spouse Relief - Internal Revenue Service Page 15
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Form 8857 (Rev. 9-2010)
Page
Part V
Tell us about your current financial situation
1
1
21
Tell us the number of people currently in your household.
Adults
Children
22
Tell us your current average monthly income and expenses for your entire household. If family or friends are helping to support
you, include the amount of support as gifts under Monthly income. Under Monthly expenses, enter all expenses, including expenses
paid with income from gifts.
Monthly income
Amount
Monthly expenses
Amount
Federal, state, and local taxes deducted
from your paycheck
.
.
.
.
.
.
250
Gifts
.
.
.
.
.
.
.
.
.
.
.
2000
620
Wages (Gross pay) .
.
.
.
.
.
.
Rent or mortgage
.
.
.
.
.
.
.
100
Pensions .
.
.
.
.
.
.
.
.
.
Utilities
.
.
.
.
.
.
.
.
.
.
40
Unemployment
.
.
.
.
.
.
.
.
Telephone
.
.
.
.
.
.
.
.
.
Social security
.
.
.
.
.
.
.
.
568
Government assistance, such as housing,
Food
.
.
.
.
.
.
.
.
.
.
.
254
food stamps, grants .
.
.
.
.
.
.
Car expenses, payments, insurance, etc.
Medical expenses, including medical
Alimony
.
.
.
.
.
.
.
.
.
.
insurance
.
.
.
.
.
.
.
.
.
200
750
10
Child support .
.
.
.
.
.
.
.
.
Life insurance
.
.
.
.
.
.
.
.
200
Self-employment business income .
.
Clothing
.
.
.
.
.
.
.
.
.
.
455
Rental income
.
.
.
.
.
.
.
.
Child care
.
.
.
.
.
.
.
.
.
Interest and dividends .
.
.
.
.
.
Public transportation
.
.
.
.
.
.
Other
income,
such
as
disability
Other expenses, such as real estate
payments, gambling winnings, etc.
taxes, child support, etc.
List the type below:
List the type below:
Type
Type
Type
Type
Type
Type
Total
.
.
.
.
.
.
.
.
.
.
2,750
Total
.
.
.
.
.
.
.
.
.
.
2,697
23
Tell us about your assets. Your assets are your money and property. Property includes real estate, motor vehicles, stocks, bonds,
and other property that you own. Tell us the amount of cash you have on hand and in your bank accounts. Also give a description of
each item of property, the fair market value of each item, and the balance of any outstanding loans you used to acquire each item. Do
not list any money or property you listed on line 20. If you need more room, attach more pages. Write your name and social security
number on the top of all pages you attach.
I have a car with a fair market value of $500, $450 in my checking account, and $100 in a savings account.
24
Please provide any other information you want us to consider in determining whether it would be unfair to hold you liable for
the tax. If you need more room, attach more pages. Write your name and social security number on the top of all pages you attach.
Caution
By signing this form, you understand that, by law, we must contact the person on line 7. See instructions for details.
Sign
Under penalties of perjury, I declare that I have examined this form and any accompanying schedules and statements, and to the best of my
knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which
Here
preparer has any knowledge.
Keep a copy
Your signature
Date
for your
Janie Boulder
8/01/2010
records.
Date
Preparer’s
Preparer's SSN or PTIN
Paid
Check if
signature
self-employed
Preparer’s
Firm’s name (or yours
EIN
Use Only
if self-employed),
address, and ZIP code
Phone no.
8857
Form
(Rev. 9-2010)
Publication 971 (September 2011)
Page 15
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