PDF document
- 1 -

Enlarge image
    Form 80-340-22-3-1-000 (Rev. 07/22)
    0606 0707 08009 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 808 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80
0404                                                                                                                                                                                                                                  0404
                                                                                                        Mississippi
0505                                                                               Affidavit for Reservation Indian                                                                                                                   0505
0606                                              Income Exclusion From Mississippi State Income Taxes                                                                                                                                0606
0707                                                                                                                                                                                                                                  0707
0808 Taxpayer First Name                                               Initial  Last Name                                                                                                         Tax Year                            0808
                                                                                                                                                                                                                    9999
0909XXXXXXXXXXXXXXXXXXXXX                                              X        XXXXXXXXXXXXXXXXXXXXX                                                                                                                                 0909
1010 Spouse First Name                                                 Initial  Last Name                                                               SSN                                                                           1010
                                                                                                                                                                                                        999999999
1111XXXXXXXXXXXXXXXXXXXXX                                              X        XXXXXXXXXXXXXXXXXXXXX                                                                                                                                 1111
1212 Mailing Address (Number and Street, Including Rural Route)                                                                                         Spouse SSN                                                                    1212
                                                                                                                                                                                                        999999999
1313X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X                                                                                                                                                                                     1313
1414 City                                                                 State    Zip                                       County Code                                                                                              1414
1515XXXXXXXXXXXXXXXXXXXXX                                              XX                      99999                               99                                                                                                 1515
1616                                                                                                                                                                                                                                  1616
1717     INDIAN STATUS    (CHECK ONE)                                                                                                                                                                                                 1717
1818                                                                                                                                                                                                                                  1818
1919(a) I am a Mississippi Choctaw Indian.                                                                       X        Yes      X        No                                                                                        1919
2020                                                                                                                                                                                                                                  2020
2121(b) I am a member or am eligible for membership in an Indian Tribe other than the Mississippi Band of Choctaws.                                                                         X        Yes      X        No             2121
2222                                                                                                                                                                                                                                  2222
2323    Name of Tribe                 XXXXXXXXXXXXXXXXXXXXX                                                                                                                                                                           2323
2424                                                                                                                                                                                                                                  2424
2525     RESERVATION RESIDENCY                                                                                                                                                                                                        2525
2626                                                                                                                                                                                                                                  2626
2727(a) During         9999              I lived on the Mississippi Choctaw Indian Reservation for... (check one box ONLY below)                                                                                                      2727
2828                                                                                                                                                                                                                                  2828
2929     X          The entire year                                                                                                                                                                                                   2929
3030     X          Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec                                        (Circle months lived on reservation)                                                                                    3030
3131     X          I did not live on the Choctaw Reservation during                           9999                                                                                                                                   3131
3232                                                                                                                                                                                                                                  3232
3333(b) My place(s) of residence on the Choctaw Reservation during 9999                                                was (were) located on (check one or more boxes below)                                                          3333
3434                                                                                                                                                                                                                                  3434
3535     X          A tribal housing site lease                                                                                                                                                                                       3535
3636     X          A Choctaw housing authority house site                                                                                                                                                                            3636
3737     X          A BIA dormitory or house                                                                                                                                                                                          3737
3838                                                                                                                                                                                                                                  3838
3939     RESERVATION INCOME                                                                                                                                                                                                           3939
4040                                                                                                                                                                                                                                  4040
4141(a) During the months I lived on the Choctaw Reservation in 9999                                             , I earned the following income from work on the Choctaw Reservation                                                 4141
4242     X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9                                                                                                                                                                   4242
4343                                                                                                                                                                                                                                  4343
4444(b) My employer(s) for my on-reservation work during 9999                                              was (were) the...             (check one or more boxes below)                                                              4444
4545                                                                                                                                                                                                                                  4545
4646     X          Mississippi Band of Choctaw Indians                                                                                                                                                                               4646
4747     X          Bureau of Indian Affairs                                                                                                                                                                                          4747
4848     X          Indian Health Service, USPHS                                                                                                                                                                                      4848
4949     X          Other                                                                                                                                                                                                             4949
5050                                                                                                                                                                                                                                  5050
5151Name of Employer                                                                                                                  Employer Phone                                                                                  5151
5252X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X                                                                                             (999)999-9999                                                                                   5252
5353Employer Address                                                                                                                                                                                                                  5353
5454X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X                                                                                    XXXXXXXXXXXXXXXXXXXXX                                             XX                99999                5454
5555I do hereby claim that the above described earned income falls outside the taxing jurisdiction of the State of Mississippi on the basis of the legal principles established in                                                    5555
5656McClanahan vs. Arizona Tax Commission , 411 U.S. 164 (1973).  THIS FORM MUST BE SIGNED.  If someone else completed this form, both of you must sign the form.                                                                     5656
    Under penalties of perjury, I           declare that I have examined this form and to the best of my knowledge and belief this form is true, correct, and complete.
5757                                                                                                                                                                                                                                  5757
5858                                                                                                                                                                                                                                  5858
5959Signature                                                                                                                            Date                                                                                         5959
6060                                                                                                                                                                                                                                  6060
6161Preparer Signature                                                                                                                   Date                                                                                         6161
6262                                                                                                                                                                                                                                  6262
6363                                                                         Mail this form to:  P.O. Box 1033, Jackson, MS 39215                                                                                                     6363
    0606 0707 08009 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 808 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80






PDF file checksum: 3871282942

(Plugin #1/9.12/13.0)