Form 84 - Application For Relief From Joint Income Tax Liability printable pdf download

Rev. 8/12

Form 84

Massachusetts

Application for Relief

Department of

from Joint Income Tax Liability

Revenue

Read the instructions before completing this form to be sure you are eligible to file. Please print or type. Names should appear as they did on

the joint return for the tax year in question.

Tax year for which relief is being requested

First name and initial

Last name

Social Security number

Telephone number

Address (including apartment number)

City/Town/Post Office

State

Zip

Spouse’s first name and initial*

Last name

Social Security number

You must have filed a joint return in order to file an Application for Relief

Questionnaire

You must answer all questions. If you answer “Yes” to any question, attach a separate statement explaining your response.

1 Have you applied for relief from federal tax liability as an innocent spouse?

Yes

No.

If yes, attach copies of the federal request for relief (including any supporting or related documentation), your applicable federal tax

return(s) and the federal determination, if any.

2 Has a Notice of Intention to Assess (NIA) been issued for the tax year for which you are requesting relief?

Yes

No.

If yes, attach a copy of the NIA. You may request a conference within 30 days after the issuance date of the NIA. If so, attach this form

to your written request for a conference.

3 Has a Notice of Assessment (NOA) been issued for the tax year for which you are requesting relief?

Yes

No.

If yes, attach a copy of the NOA and this application to Form CA-6, Application for Abatement. Complete all items on Form CA-6. In

line 1 write “see attached Form 84.” You may also request a hearing at this time by so indicating on Form CA-6 or with a separate

written request.

4 Indicate the reason and amount of your application.

Relief from joint income tax liability attributable to items omitted from gross income.

Amount of relief sought (excluding penalties and interest)

Relief from joint income tax liability attributable to a claim or claims of deduction, exemption, credit or basis.

Amount of relief sought (excluding penalties and interest)

Describe below the facts and circumstances demonstrating that you qualify for relief from liability for a substantial understatement of tax

on a joint return under MGL Ch. 62C, sec. 84. Attach any exhibits substantiating your claim. Use additional paper if necessary.

Pursuant to MGL Ch. 62C, sec. 84, the applicant named herein requests relief from joint income tax liability as an innocent spouse. Under

penalties of perjury, I declare that I have examined this form and any accompanying statements and documents and to the best of my knowl-

edge and belief the facts and statements as represented therein are true, correct and complete. I understand that if relief is granted it will

apply only to the extent specified in the Commissioner’s determination and that I will remain jointly and severally liable for any amounts

where relief is not provided. Declaration of preparer (other than taxpayer) is based on all information of which he/she has knowledge.

Applicant’s signature

Date

Preparer’s signature and attestation. I attest that I prepared this Form 84 and that I personally know/do not know (strike out one) that the statements

contained in this Form 84 are true and correct.

Preparer’s signature (Attach Form M-2848, Power of Attorney, if representing taxpayer)

Preparer’s title

Date

Form 84 - Application For Relief From Joint Income Tax Liability

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