Form 502inj - Injured Spouse Claim Form (2012)
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1
22012
INJURED SPOUSE CLAIM
FORM
502INJ
FORM
(Attach to the FRONT
of your return)
Requirements: To file an injured spouse claim, the injured spouse must have:
1. filed a joint return with the spouse owing the debt;
2. received income (such as wages, interest, etc.);
3. made payments (such as withholding and estimated tax payments); and,
4. an overpayment, all or part of which was or will be applied to the following debts owed by the other spouse: past due state or
federal taxes, past due child support or other state debt that has been referred to the Central Collection Unit.
Taxpayer Information as shown on joint tax return
Enter the names and Social Security numbers exactly as 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
First name, initial and last name shown second on the return
Social Security number shown second
If injured spouse
check here
Current home address of injured spouse
City
State
ZIP code
Daytime phone number
Is the address on your joint return different from the address shown above? . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Check this box only if you are divorced or separated from the spouse with whom you filed the joint return
and you want your refund issued in your name only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Allocation Between Spouses (see instructions)
ALLOCATION ITEMS
JOINT
INJURED SPOUSE
OTHER SPOUSE
A. Income items from Federal Forms 1040, 1040A or
1040EZ
1. Wages
2. Other income
3. Adjustments to income
B. Items from Maryland
Line numbers from Form
returns
502
503
505
505NR
1. Additions
6
N/A
20
2. Subtractions
15
N/A
7
3. Deductions
17
2
10A,10B
4. Exemptions (Enter
number from
exemptions area)
5. Earned income and/or
23, 24
7
33, 34
poverty level credit
6. Withholding taxes
39
17
43
7. Refundable earned
41
18
45
income credit
8. Estimated taxes
40
N/A
44, 46
25, 26,
35, 36,
9. Other credits
N/A
42
47
The Comptroller’s Office will calculate the amount that may be due to you based on the above information. You will be notified of the
amount. Any portion of the joint refund due to you will be issued directly from the intercepting agency if the refund has already been
intercepted.
Under penalties of perjury, I declare that I have examined this form, and to the best of my knowledge it is true, correct and complete.
If prepared by a person other than taxpayer, the declaration is based on all information of which the preparer has any knowledge.
Signature of injured spouse
Date
Signature of paid preparer
Date
Address of preparer
Street
City
State
ZIP code
COM/RAD-070
12-49
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