U.S. TREAS Form treas-irs-12507-1999
Form 12507
(December 1999)
Innocent Spouse Statement
Purpose of form: You can use this form to provide additional information to the Internal Revenue
Service (IRS) to consider in determining relief of joint and several liability for the tax year(s) at issue
in the letter you received with this form. Note: You can use the back of this page or attach additional
pages if you need more space.
My Name
Social Security Number
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. _____________________________________________:
a
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.
My Signature
Form 12507 (12-1999)
www.irs.gov
Date
Catalog Number 28728D
Department of the Treasury — Internal Revenue Service