Form 80-491-11-5-1-000 - Individual Income Tax Statement Of Additional Dependents - 2011 Page 2

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Mississippi
Individual Income Tax Statement of
Form 80-491-11-5-1-000 (Rev. 5/11)
MS
Additional Dependents
2011
804911151000
Photocopies or Duplex Forms NOT Acceptable
For Computer Use Only - Do not Write Above This Line
Duplex or Photocopies NOT Acceptable
Taxpayer NAME
Spouse Name
111-11-1111
TSSN
000-00-0000
SSSN
A dependent is a relative or other person who qualifies for federal income tax purposes as a dependent of the taxpayer.
Enter the dependent's name, the dependent's relationship to taxpayer, (Enter C for child, P for parent, R for relative) and
the dependent's Social Security Number.
Dependents
C for child, P for parent, and R for relative
(B)
Dependent's Name
(C)
Dependent's SSN
(A)
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Submit this form with both paper and electronically filed returns to ensure accuracy.
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All Taxpayers are encouraged to file their return electronically. Mississippi allows returns to be filed electronically two ways:
.
By using an approved e-file tax preparer, or
On-line by using an approved on-line service provider
Returns are more accurate and refunds are much faster when you e-file.
The Resident and Non-Resident Returns only provide spaces for four (4) dependents. Use this statement for additional
dependents. If this form is used for all dependents, enter "See Statement 1" on Line 6 of Resident and Non-Resident
Returns. Enter the total number of dependents claimed on Line 8 of return.
Disclosure Statement and Privacy Act Notice
This information will be used for identification and in the administration of state tax laws. The Department of
Revenue is authorized to collect the information pursuant to 42 U.S. C. § 405(c)(2)(C)(i). Failure to provide this
information may result in the return being considered incomplete and subject the taxpayer to a penalty. See
Miss. Code Ann. §§ 27-7-79, 27-7-81 and 27-7-87.

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