Rev. 7/03
Form M-8379
Massachusetts
Nondebtor Spouse Claim
Department of
and Allocation for Refund Due
Revenue
Important: Read the instructions below before completing this form to be sure you are eligible to file.
Tax year of expected refund:
Please print or type. Names and address should appear as they did on the joint return for the tax year in question.
Your first name and initial
Last name
Your Social Security number
Nondebtor spouse?
Yes
No
Spouse’s first name and initial*
Last name
Social Security number
Nondebtor spouse?
Yes
No
Street address (including apartment number)
City/Town/Post Office
State
Zip
Address (if present address is different from above)
Telephone number
*You must have filed a joint return in order to claim a refund due.
A.
B.
C.
Nondebtor
Other
Joint (as filed)
Allocation Items
spouse
spouse
(A) + (B)
1 Total income (list all sources here)
2 Adjustments to income
3 Deductions
4 Exemptions
5 Credits against tax (do not include Limited Income Credit)
6 Taxes withheld (include copies of all W-2 forms)
7 Tax payments (amounts paid with return, estimated, etc.)
Indicate here if the refund due is being requested in the nondebtor spouse’s name only:
Yes
No.
Under penalties of perjury, I declare that I have examined this form, and to the best of my knowledge it is true, correct and complete. Declara-
tion of preparer (other than taxpayer) is based on all information of which the preparer has knowledge.
Signature of nondebtor spouse
Date
Signature of paid preparer
Date
Paid preparer use only: Check if
Preparer’s Social Security number
self-employed
Are You Eligible to File this Form?
You may file this form if:
• you are liable for any past due tax payments to the Common-
wealth of Massachusetts.
• you filed a joint Massachusetts tax return with an overpayment
applied against the past due income tax debt of your spouse;
Enter the appropriate information from the tax return in question
where requested. The Department of Revenue will calculate
• you received income; and
your nondebtor refund based on married filing separate status.
• you made tax payments through withholding or estimated tax
Tax refunds applied to satisfy unpaid debts to other state agen-
payments.
cies must be appealed directly to that state agency. Overpay-
ments applied to child support must be appealed to Child Support
You may not file this form if:
Enforcement.
• your joint refund has been or will be applied to past due tax
Mail form to: Massachusetts Department of Revenue, PO Box
owed jointly to the Commonwealth of Massachusetts;
7010, Boston, MA 02204.
• you, as an individual, filed jointly but made no tax payments for
the tax year at issue; or