Pa Form 8857 - Request For Relief From Joint Liability Page 12

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SECTION V – INCOME AND EXPENSE ANALYSIS

(a) Income

(b) Necessary Living Expenses

47. Rent/House payment

Source

Gross

Net

48. Groceries

49. Allowable installment

(Taxpayer)

39. Wage/Salary

Payments

(Spouse)

40. Wages/Salary

50. Utilities

41. Interest - Dividends

51. Transportation

42. Net Business Income

52. Insurance

(from Form REV-484 or REV-488)

43. Rental Income

53. Medical

(Taxpayer)

44. Pension

54. Estimated tax payments

(federal-state)

Source:

(Spouse)

45. Pension

(specify)

55. Other expenses

Source:

46. TOTAL

56. TOTAL

(income less

Item 40 should be completed if you are married even if your spouse is not liable for

57. Net difference

necessary living expenses)

the tax. This information is necessary in order for the Department of Revenue to

calculate household income and expenses.

CERTIFICATION – Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities and other infor-

mation is true, correct and complete.

58. Your Signature

59. Spouse, Attorney or Accountant Signature (POA Attached)

60. Date

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