Form 8379 - Injured Spouse Allocation Page 2
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Form 8379 (Rev. 11-2016)
Page
Part III
Allocation Between Spouses of Items on the Joint Tax Return
(See the separate Form 8379 instructions for Part III.)
Allocated Items
(a) Amount shown
(b) Allocated to
(c) Allocated to
(Column (a) must equal columns (b) + (c))
on joint return
injured spouse
other spouse
13 Income:
a. Income reported on Form(s) W-2
b. All other income
14 Adjustments to income
15 Standard deduction or Itemized deductions
16 Number of exemptions
17 Credits (do not include any earned income credit)
18 Other taxes
19 Federal income tax withheld
20 Payments
Part IV
Signature. Complete this part only if you are filing Form 8379 by itself and not with your tax return.
Under penalties of perjury, I declare that I have examined this form and any accompanying schedules or 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.
Keep a copy of
Injured spouse’s signature
Date
Phone number
this form for
your records
Print/Type preparer’s name
Preparer’s signature
Date
PTIN
Paid
Check
if
self-employed
Preparer
Firm’s name
Firm’s EIN
Use Only
▶
▶
Firm’s address
Phone no.
▶
8379
Form
(Rev. 11-2016)
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