Mississippi Amended Nonresident Or Part-Year Resident Individual Income Tax Return - 2004 Page 2

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Mississippi
Amended
MS
Nonresident or Part-Year Resident
Individual Income Tax Return
TS
802700452000
2004
Page 2 of 2
Form 80-270-04-5-2-000 (Rev. 05/04)
PBC1
39A
48A
33B
42B
50B
PBC2
40A
49A
34B
43B
51B
PBC3
41A
50A
35B
44B
52B
33A
42A
51A
36B
45B
53B
34A
43A
52A
37B
46B
54B
35A
44A
53A
38B
47B
55B
36A
45A
54A
39B
48B
RS
37A
46A
55A
40B
49B
ST
38A
47A
41B
For Computer Use Only Do Not
Write Above This Line
Enter the Six Digit Principal Business
Column A
Column B
Code for Each Schedule C - Business
Total Income from All Sources
Mississippi Income Only
OTHER INCOME
33.
Business Income or Loss (Attach Federal Schedule C or C-EZ.)
34.
Wages, Salaries, Tips, Etc. (Attach W-2s.)
35.
Capital Gain or Loss (Attach Federal Schedule D.)
36.
Rental Real estate, royalties, partnerships, S corps, trusts, etc. (Attach Federal Schedule E.)
37.
Farm Income or Loss (Attach Federal Schedule F.)
38.
Interest Income (Attach Schedule B if over $400.)
39.
Dividend Income (Attach Schedule B if over $400.)
40.
Alimony Received
41.
Pensions and Annuities.
Taxable Amount
42.
Unemployment Compensation (Form(s) 1099-G)
43.
Other Income (Loss) Schedule N
44.
Total Income (Add Lines 33 through 43.)
ADJUSTMENTS TO GROSS INCOME
Total from All Sources
Mississippi Only
45.
Payments to an IRA
46.
Payments to Self-employed SEP, SIMPLE, & qualified plans.
47.
Interest Penalty on Early Withdrawal of Savings
48.
Alimony Paid (Complete Schedule P Below.)
49.
Moving Expense (Attach Federal Form 3903 or 3903F.)
50.
Lesser of National Guard/Reserve Pay or the $5,000 Statutory Exclusion Per Taxpayer.
51.
MS Prepaid Affordable College Tuition (MPACT) and/or MS Affordable College Savings (MACS)
52.
Self-Employed Health Insurance Deduction (Same as Federal Deduction)
53.
Total Adjustments (Add Lines 45 through 52.)
Total & MS Adjusted Gross Income (Subtract Line 53 from Line 44)
54.
Carry Total Column to Line 15b & Combined MS Incomes Column to Line 15a.
55.
If Filing Combined Return, Split MS AGI on Line 54 according to ownership between Taxpayer and Spouse.
Schedule P - Alimony Paid
SSN of
If a deduction is claimed for Alimony Paid, please furnish
Name
Recipient
the name, SSN, and the state of residency of the individual
State of
to whom the amount was paid.
Residency
EXPLANATION FOR CHANGES TO ORIGINAL RETURN
THIS RETURN MUST BE SIGNED. Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and
statements, and to the best of my knowledge and belief it is true, correct and complete.
Your Signature
Taxpayer's Phone
Paid Firm's Identification Number or PTIN
This Return may
be discussed with
Spouse's Signature (If joint, BOTH must sign)
Date
Paid Preparer's Social Security Number or PTIN
the preparer.
Paid Preparer's Signature
Date
No
Yes
Paid Preparer (Print Firm's Name)
Paid Preparer's Phone
Paid Preparer's Address
Mail REFUND To: Office of Revenue, P.O. Box 23058, Jackson, MS 39225-3058
Mail All Other Returns To: Office of Revenue, P.O. Box 23050, Jackson, MS 39225-3050

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