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 Date
Form 12507 (12-1999) www.irs.gov
Catalog Number 28728D
Department of the Treasury — Internal Revenue Service