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Arizona Form
Request for Innocent Spouse Relief and
200 Separation of Liability and Equitable Relief

Do not file with your tax return.

Do not use Form 200 to make an injured spouse claim. You must use Arizona Form 203 to make an injured spouse claim. You are
an injured spouse if your share of an overpayment shown on your joint return was, or is expected to be, applied against your spouse’s
past-due state taxes, child support or spousal maintenance, or debts owed to another Arizona state agency, the IRS, or a court. If you
are an injured spouse, see the note on page 1 of the instructions.

Your First Name and Middle Initial Last Name Your Social Security Number

Current Home Address - number and street, rural route Apartment Number Daytime Phone No. (optional)

City, Town or Post Office State ZIP Code

Part 1 Type of Relief. You must complete this part for each tax year.
IMPORTANT: For a request for innocent spouse relief or a request for
separation of liability, you must have filed an Arizona income tax
return for each year for which you are requesting relief.
Tax Year 1 Tax Year 2 Tax Year 3*
1 Enter each tax year you want relief. It is important to enter the correct year. For
example, if the department used your 2019 income tax refund to pay a 2017 tax
amount you jointly owned, enter tax year 2017, not tax year 2019 ................................... 1 Y Y Y Y Y Y Y Y Y Y Y Y

2 Check the box for each year you would like a refund if you qualify for relief. You
may be required to provide proof of payment. See instructions ....................................... 2   

3 For each year, check the box for the type of relief claimed. See the instructions before
you check any boxes on lines 3a through 3c. Also be sure to include all required
statements for the type of relief you are requesting.
Check all that apply:
3a Separation of Liability .................................................................................................. 3a   
3b Innocent Spouse Relief ............................................................................................... 3b   
3c Equitable Relief ........................................................................................................... 3c   

Yes No Yes No Yes No
4 Did you file a joint return for the tax year listed on line 1? ................................................. 4      
* If you want relief for more than 3
years, include a separate schedule.

If you completed federal Form 8857, you do not need to complete the rest of Form 200. Check this box and include all
required statements for the type of relief you are requesting........................................................................................................ 
If you did not complete federal Form 8857, you must complete the rest of Form 200.

DOCUMENTATION REQUIRED:
Documents • If you were granted relief by the IRS, please include a copy of the IRS letter.
• Include a copy of your completed federal Form 8857.
• Sign Form 200 on page 5.
• Mail to the address shown below.

Mail Form 200 to:
Individual Income Tax Audit • Attention Form 200
Arizona Department of Revenue
PO Box 29084 • Phoenix, AZ 85038-9084
Continued on page 2 
ADOR 10180 (21) Page 1 of 5

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Your Name (as shown on page 1) Your Social Security Number

If you need more room to write your answer to any question, add more pages.
Write your name and Social Security Number on the top of each page you include.
Part 2 Information About You and Your Spouse (or former spouse)
5 Spouse’s (or former spouse’s) Current Name Social Security Number (if known)

Current Home Address – number and street, rural route Apartment Number Daytime Phone No. (with area code)

City, Town or Post Office State ZIP Code

6 What is the current marital status between you and the person on line 5? Check one box:

 Married and still living together.

 Married and living apart since: M M D D Y Y Y Y .

 Widowed since: M M D D Y Y Y Y . Include a photocopy of the death certificate and will,
Documents if one exists.
 Legally separated since: M M D D Y Y Y Y . Include a photocopy of your entire separation agreement.

 Divorced since: M M D D Y Y Y Y . Include a photocopy of your entire divorce decree.
NOTE: A divorce decree stating that your former spouse must pay all taxes does not necessarily mean you qualify for relief.

7 What was the highest level of education you had completed when the return(s) were filed? If the answers are not the same for all
tax years, explain.

 High school diploma, equivalent, or less
 Some college
 College degree or higher. List any degrees you have:

List any college-level business or tax-related courses you completed:

Explain:

8 Were you a victim of spousal abuse or domestic violence during any of the tax years you want relief? If the answers are not the
same for all tax years, explain.
Documents
 Yes. Include a statement to explain the situation and when it started. Provide photocopies of any documentation,
such as police reports, a restraining order, a doctor’s report or letter, or a notarized statement from someone who was
aware of the situation.
 No.

9 Did you sign the return(s)? If the answers are not the same for all tax years, explain.

 Yes. If you were forced to sign under duress (threat of harm or other form of coercion), check this box: . See instructions.
 No. Your signature was forged. See instructions.

10 When any of the returns were signed, did you have a mental or physical health problem, or do you have a mental or physical
health problem now? If the answers are not the same for all tax years, explain.
Documents
 Yes. Include a statement to explain the problem and when it started. Provide photocopies of any documentation,
such as medical bills or a doctor’s report or letter.
 No.
Continued on page 3 
ADOR 10180 (21) AZ Form 200 (2021) Page 2 of 5

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Your Name (as shown on page 1) Your Social Security Number

If you need more room to write your answer to any question, add more pages.
Write your name and Social Security Number on the top of each page you include.
Part 3 Your Financial and Return Preparation Involvement
11 How were you involved with preparing the returns? Check all that apply and explain, if necessary. If the answers are not the
same for all tax years, explain:

 You filled out or helped fill out the returns.
 You gathered receipts and cancelled checks.
 You gave the tax documents (such as Forms W-2, 1099, etc.) to the person who prepared the returns.
 You reviewed the returns before they were signed.
 You did not review the returns before they were signed. Explain below.
 You were not involved in preparing the returns.
 Other:

Explain how you were involved:

12 When the returns were signed, were you concerned that any of the returns were incorrect or missing information? Check all that
apply and explain, if necessary. If the answers are not the same for all tax years, explain:

 You knew something was incorrect or missing, but you said nothing.
 You knew something was incorrect or missing and asked about it.
 You did not know anything was incorrect or missing.
Explain:

13 When any of the returns were signed, what did you know about the income of the person on line 5? If the answers are not the
same for all tax years, explain:

 You knew that person had income.

List each type of income on a separate line. (Examples are wages, social security, gambling winnings, or self-employment business income.)
Enter each tax year and the amount of income for each type listed. If you don’t know any details, enter, “I don’t know.”
Type of Income Who paid it to that person? Tax Year 1 Tax Year 2 Tax Year 3
$ $ $
$ $ $
$ $ $

 You knew that person was self-employed and you helped with the books and records.
 You knew that person was self-employed and you did not help with the books and records.
 You knew that person had no income.
 You did not know if that person had income.
Explain:

Continued on page 4 
ADOR 10180 (21) AZ Form 200 (2021) Page 3 of 5

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Your Name (as shown on page 1) Your Social Security Number

If you need more room to write your answer to any question, add more pages.
Write your name and Social Security Number on the top of each page you include.
Part 3 (Continued)
14 When the returns were signed, did you know any amount was owed to the department for those tax years? If the answers are not
the same for all tax years, explain.
 Yes. Explain when and how you thought the amount of tax reported on the return would be paid:

 No. Explain:

15 When any of the returns were signed, were you having financial problems (for example, bankruptcy or bills you could not pay)? If
the answers are not the same for all tax years, explain.

 Yes. Explain:

 No.
 Did not know.

Explain:

16 For the years you want relief, how were you involved in the household finances? Check all that apply. If the answers are not the
same for all tax years, explain.

 You knew the person on line 5 had separate accounts.
 You had joint accounts but you had limited use of them or did not use them. Explain below.
 You used joint accounts. You made deposits, paid bills, balanced the checkbook, or reviewed the monthly bank statements.
 You made decisions about how money was spent. For example, you paid bills or made decisions about household purchases.
 You were not involved in handling money for the household.

 Other:

Explain anything else you want to tell us about your household finances:

17 Has the person on line 5 ever transferred assets (money or property) to you? Property includes real estate, stocks, bonds, or
other property to which you have title. See instructions.

 Yes. List the assets and the dates they were transferred. Explain why the assets were transferred.

 No.

Continued on page 5 
ADOR 10180 (21) AZ Form 200 (2021) Page 4 of 5

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Your Name (as shown on page 1) Your Social Security Number

If you need more room to write your answer to any question, add more pages.
Write your name and Social Security Number on the top of each page you include.
Part 4 Your Current Financial Situation
18 Tell us the number of people currently in your household: Adults Children
19 Tell us your current average monthly income and expenses for your entire household. If family or friends are helping to support
you, include the amount of support as gifts under Monthly Income. Under Monthly Expenses, enter all expenses, including
expenses paid with income from gifts.
Monthly Income Amount Monthly Expenses Amount
Federal, state, and local taxes deducted from
Gifts ................................................................... $ your paycheck .................................................. $

Wages (gross pay) ............................................ $ Rent or mortgage ............................................. $

Pensions ............................................................ $ Utilities ............................................................. $

Unemployment .................................................. $ Telephone ........................................................ $

Social security ................................................... $ Food ................................................................. $
Government assistance, such as housing,
food stamps, grants ........................................... $ Car expenses, payments, insurance etc. .......... $

Alimony .............................................................. $ Medical expenses, including medical insurance $

Child support ..................................................... $ Life insurance .................................................. $

Self-employment business income .................... $ Clothing ............................................................ $

Rental income .................................................... $ Child care ......................................................... $

Interest and dividends ....................................... $ Public transportation ........................................ $
Other income, such as disability payments, Other expenses, such as real estate taxes,
gambling winnings, etc. List the type below: child support, etc. List the type below:

Type: $ Type: $

Total Monthly Income ...................................... $ Total Monthly Expenses ................................ $
20 Please provide any other information you want us to consider in determining whether it would be unfair to hold you liable for the
tax:

CAUTION: By signing this form, you understand that, by law, we must contact the person on line 5. See instructions for line 5.
Under penalties of perjury, I declare that I have examined this form and any accompanying schedules and statements, and to the best of my
knowledge and belief, they are true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which
preparer has any knowledge.


YOUR SIGNATURE DATE

PAID PREPARER’S SIGNATURE DATE FIRM’S NAME (PREPARER’S IF SELF-EMPLOYED)
PLEASE SIGN HERE
PAID PREPARER’S TIN PAID PREPARER’S ADDRESS PAID PREPARER’S PHONE NUMBER
ADOR 10180 (21) AZ Form 200 (2021) Print Form Page 5 of 5

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