PA-12508 (04-13)

                                                  NON-REQUESTING SPOUSEDEPARTMENT USE ONLY
   OFFICE OF TAXPAYERS'                             INFORMATION REQUEST 
   RIGHTS ADVOCATE                            FOR INNOCENT SPOUSE REVIEW
   LOBBY STRAWBERRY SQ
   HARRISBURG  PA  17128
Your Name:                                                                                                       Your Social Security Number:

Please answer all the questions that you can concerning the spouse and tax year(s) referenced in the letter you received
with this form. Some questions may not apply to your particular facts and circumstances or the requested information
may not be available.
1. How did you and your spouse participate in the preparation of the tax return(s) at issue?

2. Did your spouse ask you or your return preparer for an explanation of any items or amounts on the tax return(s)?

3. What is the current marital status between you and your spouse? (Please check or complete the items below that
apply to you).

          □Married  . . . . . . . . . . . . . . . . . . . . . . . . . .  Date (month, day, year)

         □Divorced  . . . . . . . . . . . . . . . . . . . . . . . . .  Date (month, day, year)

         □Legally Separated  . . . . . . . . . . . . . . . . . . .  Date (month, day, year)

         □Living Apart  . . . . . . . . . . . . . . . . . . . . . . .  Date started (month, day, year)

         □Other (Please explain)

4. Provide copies of any divorce or separation agreements where you or your spouse agreed to pay the taxes for the
year(s) at issue.

                              For forms & additional information, visit www.revenue.state.pa.us

5. How did you plan to pay the tax(es) at issue if not at the time you filed your return(s)? Was your spouse aware of your
plan?

6. If your return for the tax year(s) at issue received an administrative review or audit, what return items, if any,
changed? Were the changed items yours or your spouse’s? (For example: unreported income, disallowed deductions,
or unclaimed credits.)

7. If the administrative review or audit results changed your business income or deductions on your tax return, did your
spouse help you in the business? If so, how? If not, did your spouse know about your business affairs?

8. If the items changed by the administrative review or audit were yours, did your spouse benefit from them?

9. Were any assets transferred between you and your spouse after the beginning of the earliest tax year at issue?
Describe reasons for the transfer(s) and list dates of the transfer(s).

     For forms & additional information, visit www.revenue.state.pa.us