Pa Form 8857 - Request For Relief From Joint Liability Page 2
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12Form PA 12507 (10-09)
INNOCENT SPOUSE STATEMENT
Purpose of form: You can use this form to provide information to the PA Department of
Revenue to consider in determining relief of joint and several liability for the tax year(s) at
issue. NOTE: You can use the back of this page or attach additional pages if you need more
space.
My Name
Social Security Number
Daytime Telephone Number
Best Time to call
INNOCENT SPOUSE STATEMENT
I,
, residing at
make the following statement to be used in the determination of innocent spouse relief for
Mr./Mrs.
Under penalties of perjury, I declare that I have examined this statement, and to the best
of my knowledge and belief, it is true, correct and complete.
Signature
Date
PA Department of Revenue
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Parent category: Financial