Arizona Form 200 - Request For Innocent Spouse Relief And Separation Of Liability And Equitable Relief
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5ARIZONA FORM
Request for Innocent Spouse Relief and
200
Separation of Liability and Equitable Relief
Do not file with your tax return.
Do not use Form 200 to make an injured spouse claim. You are an injured spouse if your share of an overpayment shown on your
joint return was, or is expected to be, applied against your spouse’s past-due state taxes, child support or spousal maintenance, or debts
owed to another Arizona state agency, the IRS, or a court. If you are an injured spouse, see the note on page 1 of the instructions.
Your First Name and Middle Initial
Last Name
Your Social Security No.
Current Home Address - number and street, rural route
Apartment Number
Daytime Phone No. (optional)
Include area code
City, Town or Post Office
State
Zip Code
Part I
Type of Relief.
You must complete this part for each tax year.
IMPORTANT: You must have filed an Arizona income tax return for each year
for which you are requesting relief.
Tax Year 1
Tax Year 2
Tax Year 3*
1 Enter each tax year you want relief. It is important to enter the correct year. For
example, if the department used your 2010 income tax refund to pay a 2008 tax
Y Y Y Y
Y Y Y Y
Y Y Y Y
amount you jointly owned, enter tax year 2008, not tax year 2010 .................................
1
2 Check the box for each year you would like a refund if you qualify for relief. You
may be required to provide proof of payment. See instructions .....................................
2
3 For each year, check the box for the type of relief claimed. See the instructions before
you check any boxes on lines 3a through 3c. Also be sure to attach all required
statements for the type of relief you are requesting.
Check all that apply:
3a Separation of Liability .................................................................................................
3a
3b Innocent Spouse Relief ..............................................................................................
3b
3c Equitable Relief ..........................................................................................................
3c
Yes
No
Yes
No
Yes
No
4 Did you file a joint return for the tax year listed on line 1? ...............................................
4
* If you want relief for more than 3
years, attach a separate schedule.
If you completed federal Form 8857, you do not need to complete the rest of Form 200. Check this box and .........................
attach all required statements for the type of relief you are requesting. If you did not complete federal Form 8857, you must
complete the rest of Form 200.
ATTACHMENTS REQUIRED:
• If you were granted relief by the IRS, please attach a copy of the IRS letter.
• Attach a copy of your completed federal Form 8857.
• Sign Form 200 on page 5.
• Mail to the address shown below.
Mail Form 200 to:
Arizona Department of Revenue • Individual Income Tax Audit
Room 520, Attention Form 200
1600 West Monroe • Phoenix, AZ 85007-2650
Continued on page 2
ADOR 10180 (12)
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