Form 80-110-12-8-1-000 - Mississippi Ez Individual Income Tax Return - 2012

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Form 80-110-12-8-1-000 (Rev. 7/12)
MS
Mississippi
EZ Individual
Income Tax Return
801101281000
Amended
2012
This form is for a SINGLE person with no dependents, having wages & interest income only.
Taxpayer Last Name
First Name
Middle Initial
YOU MUST ENTER SSN
Mailing Address (Number & Street, Including Rural Route)
SSN
__ __ __ - __ __ - __ __ __ __
State
City
Zip
Residence County Code
__ __
See Instructions Form 80-100
See instructions on back of form
ROUND TO THE NEAREST DOLLAR
__, __ __ __, __ __ __.
00
1. Wages, Salaries, Tips, etc.
(Must Complete Form 80-107)
2. Taxable Interest Income
__, __ __ __, __ __ __.
00
3. Mississippi Adjusted Gross Income
__, __ __ __, __ __ __.
00
(Line 1 plus Line 2)
4. Total of Exemption and Standard Deduction
$8,300.00
5. Taxable Income
If Less Than 0, Enter 0
__, __ __ __, __ __ __.
00
(Line 3 minus Line 4)
6. Total Income Tax Due
(See Table on back)
__, __ __ __, __ __ __.
00
7. Consumer Use Tax
__, __ __ __, __ __ __.
00
8. Total Tax Due
__, __ __ __, __ __ __.
00
(Line 6 plus Line 7)
__, __ __ __, __ __ __.
00
9. Mississippi Income Tax Withheld
(From Form 80-107)
__, __ __ __, __ __ __.
00
10. Amount Paid with Original Return
(Amended Return Only)
__, __ __ __, __ __ __.
00
11. Total Payments
(Line 9 plus Line 10)
__, __ __ __, __ __ __.
00
12. Refund Received from Original Return
(Amended Return Only)
13. Overpayment
__, __ __ __, __ __ __.
00
(If Line 11 is larger than Line 8 plus Line 12)
Voluntary Contribution Check-offs
__, __ __ __.
00
Military Family Relief Fund
__, __ __ __.
00
Bicentennial Celebration Fund
Burn Care Fund
__, __ __ __.
00
__, __ __ __.
00
Wildlife Fisheries and Parks Foundation
__, __ __ __.
00
Wildlife Heritage Fund
__, __ __ __.
00
Commission for Volunteer Service Fund
__, __ __ __.
00
Educational Trust Fund
__, __ __ __, __ __ __.
00
14. Enter Total Contributions
__, __ __ __, __ __ __.
00
15. Refund
(Line 13 minus Line 14)
16. Balance Due
__, __ __ __, __ __ __.
00
(If Line 8 plus Line 12 is larger than Line 11)
17. Interest and Penalty
__, __ __ __, __ __ __.
00
(Including Interest on Underpayment of Estimated Tax, Form 80-320)
18. Total Due
Must Attach Check or Money Order
__, __ __ __, __ __ __.
00
(Line 16 plus Line 17)
Payable to: Department of Revenue
Yes
No
Installment Agreement Request (See Instructions for eligibility).
This Return may be discussed with the preparer.
I declare, under penalties of perjury, that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief,
this is a true, correct and complete return. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
__ __ __ __ __ __ __ __ __
Date
Taxpayer Signature
Taxpayer Phone Number
Paid Preparer PTIN
Date
Paid Preparer Email Address
Spouse Signature
Paid Preparer Phone Number
Date
Paid Preparer Signature
Paid Preparer Address
City
Zip Code
State
Mail REFUND To: Department of Revenue, P.O. Box 23058, Jackson, MS 39225-3058
Mail All Other Returns To: Department of Revenue, P.O. Box 23050, Jackson, MS 39225-3050
Duplex and Photocopies NOT Acceptable

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