Mississippi Amended Individual Income Tax Return

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Mississippi
MS
IA
Amended Individual Income Tax Return
YEAR:
801700251000
Form 80-170-02-5-1-000 (Rev. 07/02)
Page 1
CC:2
Resident
Nonresident
Check Applicable Block:
13B
16B
19
22
25
14B
17B
20
23
26
15B
18B
21
24
TS
SS
N1
N2
N3
TY
N4
N5
N6
PS
A
C1
C2
C3
For Computer Use Only - Do Not Write Above This Line
Your SSN
Spouse SSN
B. Net Change - Increase/Decrease
A. As Originally Reported
Change in Tax
C. Correct Amount
(Indicate Decrease by placing - sign to left of amount)
or as Adjusted
(EXPLAIN BELOW)
Mississippi Taxable Income (Enter in Column B the
13.
13.
amount from Line 9 of page 2.)
14.
Total Income Tax Due
(G)
14.
15.
Mississippi Income Tax Withheld
(W)
15.
Estimate Tax Payment & Amount paid with
16.
(E)
16.
Extension
Credit form Income Tax Paid To Another
17.
(S)
17.
State
18.
Other Credits
(O)
18.
Amount Paid with Original Return, Plus
19.
19.
Additional Tax Paid
Total Credits (Add Lines 15C through
20.
20.
19C)
Overpayment, if any, Shown on Original Return (or as previously adjusted) (NOTE: Enter the amount of overpayment on the
original return BEFORE any portion thereof was applied to estimated tax or a designated contribution.)
21.
21.
22.
Net Tax Paid for This Period (Subtract Line 21 from Line 20C.)
22.
23.
Enter the Amount of REFUND to be Received if Line 22 is greater than Line 14C.
REFUND
(R)
23.
24.
Enter the BALANCE DUE if Line 14C is greater than Line 22.
BALANCE DUE
24.
25.
INTEREST @ 1% PER MONTH on Line 24 from Original Due Date of Return until Date Paid
(T)
25.
TOTAL DUE (Add Lines 24 and 25). Attach Check or Money Order for Total Due
26.
TOTAL DUE
(V)
26.
payable to: State Tax Commission
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, is true, correct, and complete.
If Joint
Return, Both
Your Signature
Telephone Number (Daytime)
Date
Must Sign
Date
Spouse's Signature (If Filing Joint Return, Both Must Sign)
Preparer's Signature (other than taxpayer)
Date
Preparer's FEIN
Preparer's SSN
Mail REFUND to: Office of Revenue, P. O. Box 23058, Jackson, MS 39225-3058
Mail TAX DUE to: Office of Revenue, P. O. Box 23050, Jackson, MS 39225-3050

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