Publication 971 - Instructions Innocent Spouse Relief Forms

Request for Innocent Spouse Relief

8857

Form

OMB No. 1545-1596

(And Separation of Liability and Equitable Relief)

(Rev. May 2002)

Department of the Treasury

Do not file with your tax return.

See instructions.

(99)

Internal Revenue Service

Do not file this form if:

● You did not file a joint return for the year(s) for which you are requesting relief. However, if you lived in a community

property state, see instructions.

● All or part of your overpayment was (or is expected to be) applied against your spouse’s past-due debt (such as child

support). Instead, file Form 8379, Injured Spouse Claim and Allocation, to apply to have your share of the overpayment

refunded to you.

To see if you may qualify for Innocent Spouse Relief, go to , click on “Individuals,” “Innocent

Spouses,” and “Explore if you are an Eligible Innocent Spouse”; or see Pub. 971, Innocent Spouse Relief.

Your social security number

Your current name (see instructions)

Part I

Janie Boulder

1 2 3

0 0

9 8 7 6

See Spousal

Your current home address (number and street). If a P.O. box, see instructions.

Apt. no.

Notification

5161 Old Farm Estates

in the

instructions.

City, town or post office, state, and ZIP code. If a foreign address, see instructions.

Daytime phone number

(

)

Hutchinson, IA 55555

7 2 1

5 5 5 - 1 0 2 3

If you have been a victim of domestic abuse and fear that filing a claim for innocent

spouse relief will result in retaliation, check here

2 0 0 1

1 Enter the year(s) for which you are requesting relief from liability of tax

Part II

2 Information about the person to whom you were married as of the end of the year(s) on line 1.

Name

Social security number

Joe E. Boulder

2 3 4

0 0

8 7 6 5

Current home address (number and street). If a P.O. box, see instructions.

Apt. no.

3898 Timber Way

City, town or post office, state, and ZIP code. If a foreign address, see instructions.

Daytime phone number

(

)

Creekbed, WY 77777

2 7 1 5 5 5 - 2 3 4 5

3 Do you have an Understatement of Tax (that is, the IRS has determined there is a difference between

the tax shown on your return and the tax that should have been shown)?

Yes. Go to Part III.

No. Go to Part V.

Part III

4 Are you divorced from the person listed on line 2 or has that person died?

Yes. Go to line 7.

No. Go to line 5.

5 Are you legally separated from the person listed on line 2?

Yes. Go to line 7.

No. Go to line 6.

6 Have you lived apart from the person listed on line 2 at all times during the 12-month period prior to filing

this form?

Yes. Go to line 7.

No. Go to Part IV.

7 If line 4, 5, or 6 is Yes, you may request Separation of Liability by attaching a statement (see instructions).

Check here

and go to Part IV.

Part IV

8 Is the understatement of tax due to the Erroneous Items of your spouse (see instructions)?

Yes. You may request Innocent Spouse

No. You may request Equitable Relief for

Relief by attaching a statement (see

the understatement of tax. Check Yes in

instructions). Go to Part V.

Part V.

Part V

9 Do you have an Underpayment of Tax (that is, tax that is properly shown on your return but not paid) or

another tax liability that qualifies for Equitable Relief (see instructions)?

Yes. You may request Equitable Relief by

No. You cannot file this form unless line 3

attaching a statement (see instructions).

is Yes.

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 preparer has any knowledge.

Sign Here

Your signature

Date

Keep a copy

Janie Boulder

for your records.

4/28/2003

Date

Preparer’s SSN or PTIN

Preparer’s

Paid

Check if

signature

self-employed

Preparer’s

Firm’s name (or yours

EIN

Use Only

if self-employed),

Phone no. (

)

address, and ZIP code

8857

For Privacy Act and Paperwork Reduction Act Notice, see instructions.

Cat. No. 24647V

Form

(Rev. 5-2002)

Page 14

Publication 971 - Instructions Innocent Spouse Relief Forms - 2003 Page 14

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