EFTA01222786.pdf

Injured Spouse Allocation Form 8379 (Rev. November 2016) OMB No. 1645-0074 Depanment of the Treasury to Information about Form 8379 and its separate Instructions is at www.lrs.gov/form8379. Attachment Internal Revenue Sewte Sequence No. 104 Part I Should You File This Form? You must complete this part. 1 Enter the tax year for which you are filing this form. ► Answer the following questions for that yea . 2 Did you (or will you) file a joint return? O Yes. Go to line 3. O No. Stop here. Do not file this form. You are not an injured spouse. 3 Did (or will) the IRS use the joint overpayment to pay any of the following legally enforceable past-due debt(s) owed only by your spouse? (see instructions) • Federal tax • State income tax • State unemployment compensation • Child support • Spousal support • Federal nontax debt (such as a student loan) O Yes. Go to line 4. O No. Stop here. Do not file this form. You are not an injured spouse. Note: If the past-due amount is for a federal tax liability owed by both you and your spouse. you may qualify for innocent spouse relief for the year to which the joint overpayment was (or will be) applied. See Innocent Spouse Relief in the instructions. 4 Are you legally obligated to pay this past-due amount? O Yes. Stop here. Do not file this form. You are not an injured spouse. Note: If the past-due amount is for a federal tax liability owed by both you and your spouse. you may qualify for innocent spouse relief for the year to which the joint overpayment was (or will be) applied. See Innocent Spouse Relief in the instructions. O No. Go to line 5a. 5a Were you a resident of a community property state at any time during the tax year entered on line 1? (see instructions) O Yes. Enter the name(s) of the community property state(s) Go to line 5b. O No. Skip line 5b and go to line 6. b If you answered "Yes" on line 5a, was your marriage recognized under the laws of the community property state(s)? (see instructions) O Yes. Skip lines 6 through 9. Go to Part II and complete the rest of this form. O No. Go to line 6. 6 Did you make and report payments, such as federal income tax withholding or estimated tax payments? O Yes. Skip lines 7 through 9 and go to Part II and complete the rest of this form. O No. Go to line 7. 7 Did you have earned income, such as wages. salaries, or self-employment income? O Yes. Go to line 8. O No. Skip line 8 and go to line 9. 8 Did (or will) you claim the earned income credit or additional child tax credit? O Yes. Skip line 9 and go to Part II and complete the rest of this form. O No. Go to line 9. 9 Did (or will) you claim a refundable tax credit? (see instructions) ❑ Yes. Go to Part II and complete the rest of this form. ❑ No. Stop here. Do not file this form. You are not an injured spouse. Part II Information About the Joint Tax Return for Which This Form Is Filed 10 Enter the following information exactly as it is shown on the tax return for which you are filing this form. The spouse's name and social security number shown first on that tax return must also be shown first below. First name. initial. and last name shown first on the return Social security number shown first If Injured Spouse, check here e O First name. initial. and last name shown second on the return Social security number shown second If Injured Spouse, check here► O 11 Check this box only ff you want your refund issued in both names. Otherwise, separate refunds will be issued for each spouse, if applicable O 12 Do you want any injured spouse refund mailed to an address different from the one on your joint return? O Yes O No If "Yes." enter the address. Number and street City, town or post office, state, and ZIP code For Paperwork Reduction Act Notice, see separate Instructions. Form 8379 (Rev. 11-2016) EFTA01222786 Fem., 8379 (Rev. 11-2016) Page 2 Allocation Between Spouses of Items on the Joint Tax Return (See the separate Form 8379 instructions for Part III. Allocated Items (a) Amount shown (b) Allocated to (c) Allocated to (Column (a) must equal columns (b) + (c)) on joint return injured spouse other spouse 13 Income: a. Income reported on Forrn(s) W-2 b. All other income 14 Adjustments to income 15 Standard deduction or Itemized deductions 16 Number of exemptions 17 Credits (do not include any earned income credit) 18 Other taxes 19 Federal income tax withheld 20 Payments k•rnata ainnat era f•rwinnlarsin 11.•;. nm. •-•nhe Stems m,. Clint. Cnrre• 2Q70 It.. ii.calf nnel nni.•••ak Item or +ene reek own Under penalties of perjury. I declare that I have examined this form and any accompanying schedules or statements and to the best of my knowledge and belief, they am true, correct. and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Keep a copy of Injured spouse's signature Date Phone number this form for your records Print/Type preparers name Prepares signature Date PT1N Paid Check ❑0 if self-empfoyed Preparer Use Only Firn's name ii. Finn's EIN Pk Frm's address II. Phone no. Form 8379 (Rev. 11-2016) EFTA01222787