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Key to the data fields for the Individual Income Tax Statement of Additional Dependents form scanband version for 2011.

The form number is 80-491.

Page 1:

The top left corner of the barcode is located at position x=6, y=4 on the 10/6 grid.

The top right registration mark is located at the top right corner of grid box x=80, y=4.

The lower left corner of the scanband box must be located on the left and bottom edge of grid space x=6, y=18.

"MS" to the left of the header must begin in grid space 27/4 and end in grid space 28/4 and be in an Courier 12 pt.

Page 2:

The top left corner of the barcode is located at position x=6, y=4 on the 10/6 grid.

The top right registration mark is located at the top right corner of grid box x=80, y=4.

The lower left corner of the scanband must be located on the left and bottom edge of grid space x=6, y=19.

"MS" to the left of the header must begin in grid space 27/4 and end in grid space 28/4 and be in an Courier 12 pt.

The following is the labeling and the description of the items to be included in the Scanband of this form. The beginning and ending data

positions are included in one of the templates for the form. The field length is included in this key for each data position. Grid positioning

given is from the first grid space to the last grid space included in a data field. (Example 22/9 to 29/9 is 8 grid spaces) You should use this

information to position the data on the returns. Do not use a grid overlay to determine the positions from a printed paper form. The field

length specified assumes using a Courier 12 point font, which is the required font. In the Scanband, the dependents fields C for child,

P parent and R relative should be left justified. All other fields should be right justified. All fields in the scanband must be filled,

except if there is no spouse. If a field is Blank in the scanband, your software should fill the field using a "0" (zero) for numeric

fields and an "N" for alpha or alphanumeric fields. The numeric fields in the scanband should not contain any commas, cents, decimals

or other formatting information. The numeric fields in the body of the return should contain dashs (Example: SSN 999-99-9999) in the body

of the form.

Page 1) of the form:

Field Name

Description

TSSN

This is a numeric field. This is the taxpayer's Social Security Number. This field is 10 characters long. The last digit in this

field is a check digit. This check digit is in the scanband but not in the body of the form. Check digits should be calculated

using Modulus 10 Self-check Digit Computation found in the Mississippi Guidelines for Provider of Substitute Forms.

SSSN

This is a numeric field. This is the spouse's Social Security Number. This field is 10 characters long. The last digit in this

field is a check digit.This check digit is in the scanband but not in the body of the form. Check digits should be calculated

using Modulus 10 Self-check Digit Computation found in the Mississippi Guidelines for Provider of Substitute Forms.

B1 - B20

These fields are alpha fields, for dependents and indicate relationship to taxpayer. A code should be entered: C for child,

P for parent, and R for relative. The code should go in the scanband and in the body of the form under DEPENDENTS.

These fields are 1 character long.

C1 - C20

These fields are numeric field. This is the dependents Social Security Number. This field is 10 characters long. The last

digit in this field is a check digit.This check digit is in the scanband but not in the body of the form. Check digits should be

calculated using Modulus 10 Self-check Digit Computation found in the Mississippi Guidelines for Provider of Substitute

Forms.

Form 80-491-11-5-1-000 - Individual Income Tax Statement Of Additional Dependents - 2011 Page 6