Publication 971 (Rev. April 2008) - Innocent Spouse Relief Page 15
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234
Form 8857 (Rev. 6-2007)
Page
Part V
Tell us about your current financial situation
1
1
20
Tell us the number of people currently in your household.
Adults
Children
21
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
250
Gifts
from your paycheck
2,000
620
Wages (Gross pay)
Rent or mortgage
100
Pensions
Utilities
40
Unemployment
Telephone
Social security
568
Food
Government assistance, such as housing,
254
food stamps, grants
Car expenses, payments, insurance, etc.
Alimony
Medical expenses, including medical
200
insurance
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
2,750
2,697
Total
Total
22
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. Be sure to 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
Here
on all information of which preparer has any knowledge.
Your signature
Date
Keep a copy
for your
Janie Boulder
8/01/2007
records.
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
Form
(Rev. 6-2007)
Publication 971 (April 2008)
Page 15
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