Arizona Form 200 - Request For Innocent Spouse Relief And Separation Of Liability And Equitable Relief Page 5
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1
2
3
4
5Your Name (as shown on page 1)
Your Social Security Number
If you need more room to write your answer to any question, add more pages. Write your name and social security number on the top of each page you include.
Part 4
Your Current Financial Situation
18 Tell us the number of people currently in your household: Adults
Children
19 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 from
$
$
Gifts ...................................................................
your paycheck ..................................................
$
$
Wages (gross pay) ............................................
Rent or mortgage .............................................
$
$
Pensions ............................................................
Utilities .............................................................
$
$
Unemployment ..................................................
Telephone ........................................................
$
$
Social security ...................................................
Food .................................................................
Government assistance, such as housing,
$
$
food stamps, grants ...........................................
Car expenses, payments, insurance etc. ..........
$
$
Alimony ..............................................................
Medical expenses, including medical insurance
$
$
Child support .....................................................
Life insurance ..................................................
$
$
Self-employment business income ....................
Clothing ............................................................
$
$
Rental income ....................................................
Child care .........................................................
$
$
Interest and dividends .......................................
Public transportation ........................................
Other income, such as disability payments,
Other expenses, such as real estate taxes,
gambling winnings, etc. List the type below:
child support, etc. List the type below:
$
$
Type:
Type:
$
$
Type:
Type:
$
$
Type:
Type:
Yellow-colored fields calculate and are read-only. You cannot enter data in these fields.
$
$
Total Monthly Income ......................................
Total Monthly Expenses ................................
20 Please provide any other information you want us to consider in determining whether it would be unfair to hold you liable for the
tax:
CAUTION: By signing this form, you understand that, by law, we must contact the person on line 5. See instructions for line 5.
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 on all information of which
preparer has any knowledge.
YOUR SIGNATURE
DATE
PAID PREPARER’S SIGNATURE
DATE
FIRM’S NAME (PREPARER’S IF SELF-EMPLOYED)
PAID PREPARER’S TIN
PAID PREPARER’S ADDRESS
PAID PREPARER’S PHONE NUMBER
ADOR 10180 (14)
Page 5 of 5
AZ Form 200 (2014)
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