Form 8857 - Request For Innocent Spouse Relief Page 5
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Form 8857 (Rev. 1-2014)
Page
Note. If you need more room to write your answer for any question, attach more pages. Be sure to write your name and social security
number on the top of all pages you attach.
Part IV
Tell us about your current financial situation (Continued)
22
How many people are currently in your household, including yourself?
Adults
Children
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Tell us your current average monthly income and expenses for your entire household.
Monthly Income — If family or friends are helping to support you, include the amount of support as gifts below.
Amount
Gifts
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Wages (Gross pay) .
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Pensions .
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Unemployment
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Social security
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Government assistance, such as housing, food stamps, grants .
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Alimony
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Child support .
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Self-employment business income
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Rental income
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Interest and dividends .
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Other income, such as disability payments, gambling winnings, etc. List each type below:
Type
Type
Type
Total Monthly Income
Monthly Expenses — Enter all expenses, including expenses paid with income from gifts.
Amount
Food and Personal Care:
Food
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Housekeeping supplies
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Clothing and clothing services
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Personal care products and services
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Transportation:
Auto loan/lease payment, gas, insurance, licenses, parking, maintenance, etc.
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Public transportation
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Housing and Utilities:
Rent or mortgage
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Real estate taxes and insurance
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Electric, oil, gas, water, trash, etc.
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Telephone and cell phone
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Cable and Internet
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Medical:
Health insurance premiums
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Out-of-pocket expenses
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Other:
Child and dependent care
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Caregiver expenses
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Income tax withholding (federal, state, and local)
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Estimated tax payments
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Term life insurance premiums
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Retirement contributions (employer required)
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Retirement contributions (voluntary)
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Union dues
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Unpaid state and local taxes (minimum payment)
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Student loans (minimum payment)
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Court-ordered debt payments (for example, court- or agency-ordered child support, alimony and
garnishments). List each type below:
Type
Type
Type
Miscellaneous
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Total Monthly Expenses
8857
Form
(Rev. 1-2014)
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