Rev. 7/03
                                                                   Form M-8379                                            Massachusetts
                                                    Nondebtor Spouse Claim                                                Department of
                                                                                                                          Revenue
                                           and Allocation for Refund Due

Important: Read the instructions below before completing this form to be sure you are eligible to file.
Tax year of expected refund:
Please print or type. Names and address should appear as they did on the joint return for the tax year in question.
Your first name and initial                Last name                      Your Social Security number             Nondebtor spouse?
                                                                                                                  Yes         No
Spouse’s first name and initial*           Last name                      Social Security number                  Nondebtor spouse?
                                                                                                                  Yes         No
Street address (including apartment number)                               City/Town/Post Office                   State      Zip

Address (if present address is different from above)                                                              Telephone number

*You must have filed a joint return in order to claim a refund due.

                                                                                                     A.           B.                  C.
                                                                                            Nondebtor                     Other               Joint (as filed)
Allocation Items                                                                                spouse            spouse(A) + (B)
1Total income (list all sources here)
2Adjustments to income
3Deductions
4Exemptions
5Credits against tax (do not include Limited Income Credit)
6Taxes withheld (include copies of all W-2 forms)
7Tax payments (amounts paid with return, estimated, etc.)
Indicate here if the refund due is being requested in the nondebtor spouse’s name only:Yes     No.

Under penalties of perjury, I declare that I have examined this form, and to the best of my knowledge it is true, correct andomplete.cDeclara-
tion of preparer (other than taxpayer) is based on all information of which the preparer has knowledge.
Signature of nondebtor spouse                                             Date

Signature of paid preparer                                                Date

Paid preparer use only:    Check if                                       Preparer’s Social Security number
                           self-employed 

Are You Eligible to File this Form?
You may file this form if:                                                • you are liable for any past due tax payments to the Common-
                                                                          wealth of Massachusetts.
• you filed a joint Massachusetts tax return with an overpayment
applied against the past due income tax debt of your spouse;              Enter the appropriate information from the tax return in question
                                                                          where requested. The Department of Revenue will calculate
• you received income; and
                                                                          your nondebtor refund based on married filing separate status.
• you made tax payments through withholding or estimated tax
                                                                          Tax refunds applied to satisfy unpaid debts to other state agen-
payments.
                                                                          cies must be appealed directly to that state agency. Overpay-
You may not file this form if:                                            ments applied to child support must be appealed to Child Support
                                                                          Enforcement.
• your joint refund has been or will be applied to past due tax
owed jointly to the Commonwealth of Massachusetts;                        Mail form to:  Massachusetts Department of Revenue, PO Box
                                                                          7010, Boston, MA 02204.
• you, as an individual, filed jointly but made no tax payments for
the tax year at issue; or