Form 80-340-07-8-1-000 - Affidavit In Support Of Reservation Indian Income Exclusion From Mississippi State Income Taxes - 2007

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Form 80-340-07-8-1-000 (Rev. 05/07)
Mississippi
Route to
Affidavit In Support Of
IIT
Reservation Indian Income Exclusion From
Mississippi State Income Taxes
Tax Year _________
Your first name & middle initial
Last Name
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Mailing Address (Number & Street, Including Rural Route)
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Residence County Code - See Instructions
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Indian Status (Check One)
(a) I am a Mississippi Choctaw Indian.
Yes
No
(b) I am a member or am eligible for membership in an
OR
Indian Tribe other than the Mississippi Band of Choctaws.
Yes
No
Name of Tribe
Reservation Residency
(a) During
I lived on the Mississippi Choctaw Indian Reservation for (Check one box ONLY below.)
The entire year.
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec (Circle months lived on reservation.)
I did not live on the Choctaw Reservation during
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(b) My place(s) of residence on the Choctaw Reservation during
was (were) located on (Check one or more boxes below.)
A tribal housing site lease.
A Choctaw housing authority house site.
A BIA dormitory or house.
Reservation Income
(a) During the months I lived on the Choctaw Reservation in
, I earned the following income from work on the Choctaw
Reservation
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(b) My employer(s) for my on-reservation work during
was (were) the (Check one or more boxes below.)
Mississippi Band of Choctaw Indians.
Bureau of Indian Affairs.
Indian Health Service, USPHS.
Other:
Name of Employer
Employer's Phone
.
Employer's Address
I 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 McClanahan 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 return. Under penalties of perjury, I
declare that I have examined this form and to the best of my knowledge and belief it is true, correct, and complete.
Your Signature
Date
Preparer's Signature
Date
Mail this form and your State Tax Return to:
Office of Revenue
P.O. Box 23050
Jackson, MS 39225-3050

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