Form 80-205-12-8-1-000 - Mississippi Non-Resident / Part-Year Resident Individual Income Tax Return - 2012 Page 2

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Mississippi
Form 80-205-12-8-2-000 (Rev. 05/12)
MS
Non-Resident or Part-Year Resident
Page 2
Individual Income Tax Return
802051282000
2012
ROUND TO NEAREST DOLLAR
__ __ __ - __ __ - __ __ __ __
Mississippi Income ONLY
SSN
Total Income From All Sources
38. Wages, Salaries, Tips, Etc. (Complete Form 80-107)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
39. Business Income (Loss) (Must Attach Federal
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
Schedule C or C-EZ)
40. Capital Gain (Loss) (Must Attach Federal Schedule D)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
41. Rent, Royalties, Partnerships, S-Corps, Trusts, etc.
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
(From Form 80-108, Part 4)
42. Farm Income (Loss) (Must Attach Federal Schedule F)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
43. Interest Income (From Form 80-108, Part 2)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
44. Dividend Income (From Form 80-108, Part 2)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
45. Alimony Received
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
46. Taxable Pensions and Annuities (Complete Form 80-107)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
47. Unemployment Compensation (Complete Form 80-107)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
48. Other Income (Loss) (From Form 80-108, Part 5)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
49. Total Income (Add Lines 38 through 48)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
50. Payments to IRA
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
51. Payments to Self-employed SEP,
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
SIMPLE, & Qualified Retirement Plans
52. Interest Penalty on Early Withdrawal of Savings
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
53. Alimony Paid (Must Complete Below)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
__ __ __ - __ __ - __ __ __ __
Name:
SSN
__ __
State
__ __ __ - __ __ - __ __ __ __
Name:
SSN
__ __
State
54. Moving Expense (Must Attach Federal Form 3903)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
55. National Guard or Reserve Pay (Enter the Lesser of the Guard/
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
Reserve Pay or the $15,000 Statutory Exclusion Per Taxpayer)
56. MS Prepaid Affordable College Tuition (MPACT)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
57. MS Affordable College Savings (MACS)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
58. Self-Employed Health Insurance Deduction
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
59. Health Savings Account Deduction
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
60. Total Adjustments (Add Lines 50 through 59)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
61. Adjusted Gross Income (Line 49 minus Line 60)
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
00
Carry Total AGI to Line 15b & MS AGI Line 15a
62. Split MS AGI on Line 61
T
__, __ __ __, __ __ __.
00
S
__, __ __ __, __ __ __.
00
between Taxpayer & Spouse
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
Spouse Signature
Date
Paid Preparer Email Address
Paid Preparer Phone Number
Paid Preparer Signature
Date
Paid Preparer Address
City
State
Zip Code
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

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