Form 80-108-12-8-1-000 - Mississippi Adjustments & Contributions - 2012

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Form 80-108-12-8-1-000 Rev. (05/12)
MS
Mississippi
Page 1
Adjustments & Contributions
801081281000
2012
SSN
Taxpayer Name
__ __ __ - __ __ - __ __ __ __
PART 1: SCHEDULE A - Itemized Deductions (From Federal Form 1040 Schedule A)
(MUST COMPLETE FULLY.)
In the event you filed using the standard deduction on your Federal Return and wish to itemize for Mississippi purposes, use Federal Form 1040 Schedule A as a worksheet and transfer
the information from the specific lines indicated to this Schedule A.
ROUND TO THE NEAREST DOLLAR
.
00
1.
a
Medical and Dental Expenses (Must Attach Federal Form 1040 Schedule A)
__, __ __ __, __ __ __.
b. AGI from Federal Form 1040 $
X 7.5%(.075)
00
__, __ __ __, __ __ __.
00
c. Medical & Dental Expense Deduction (Subtract line 1b from line 1a)
__, __ __ __, __ __ __.
2.
a. Total Taxes Paid
00
__, __ __ __, __ __ __.
00
b. Less State Income Taxes (or other taxes in lieu of)
__, __ __ __, __ __ __.
c. Total Taxes Paid Deduction (Line 2a minus Line 2b)
00
__, __ __ __, __ __ __.
00
3.
Total Interest Paid
__, __ __ __, __ __ __.
4.
Charitable Contributions
00
__, __ __ __, __ __ __.
00
5.
Total Casualty or Theft Loss (Must Attach Federal Form 4684)
__, __ __ __, __ __ __.
6.
00
a. Employee Business Expenses (Must Attach Federal Form 2106)
__, __ __ __, __ __ __.
b. Miscellaneous Itemized Deductions
(6a & 6b subject to 2% limitation)
00
__, __ __ __, __ __ __.
c. AGI from Federal Form 1040 $
X 2%(.02)
00
__, __ __ __, __ __ __.
00
__, __ __ __, __ __ __.
d. Line 6a plus 6b minus 6c
00
7.
a. Other Miscellaneous Deductions
__, __ __ __, __ __ __.
00
b. Less MS Gambling Losses
__, __ __ __, __ __ __.
c. Other Miscellaneous Deduction (Line 7a minus Line 7b)
00
__, __ __ __, __ __ __.
8.
Mississippi Itemized Deductions - (Add Lines 1c, 2c, 3, 4, 5, 6d, and 7c.) Enter the amount here and on
00
__, __ __ __, __ __ __.
Resident Form 80-105, Page 1, Line 19 or Non-Resident Form 80-205, Page 1, Line 16a.
PART 2: SCHEDULE B - Interest and Dividend Income
(From Federal Form 1040 Schedule B, enter the amount from the line indicated)
00
1.
Interest Income From All Sources
__, __ __ __, __ __ __.
2. Amount of MS Non-Taxable Interest in Line 1
00
__, __ __ __, __ __ __.
3. Total MS Interest (Line 1 minus Line 2, Enter here and on Form 80-105, Line 43 or
00
__, __ __ __, __ __ __.
Form 80-205, Line 43)
00
4. Total Dividends From All Sources
__, __ __ __, __ __ __.
5. Amount of MS Nontaxable Distributions Reported in Line 4
00
__, __ __ __, __ __ __.
6. Total MS Dividends (Line 4 minus Line 5, Enter here and on Form 80-105, Line 44 or
00
__, __ __ __, __ __ __.
Form 80-205, Line 44)
PART 3: VOLUNTARY CONTRIBUTION CHECK-OFFS (Residents Only)
You may elect to voluntarily contribute all or part (at least $1) of your income tax refund to one or more of the funds listed below. Refer to the instruction booklet 80-100 (may
be downloaded from our website ) for an explanation of the purpose of each of these funds and how the refund donations will be used.
Military Family Relief Fund
00
Bicentennial Celebration Fund
00
__, __ __ __.
__, __ __ __.
Burn Care Fund
Wildlife Fisheries and Parks Foundation
00
00
__, __ __ __.
__, __ __ __.
Wildlife Heritage Fund
Commission for Volunteer Service Fund
00
00
__, __ __ __.
__, __ __ __.
Educational Trust Fund
00
__, __ __ __.
00
Enter Total of Check-Offs here and on Form 80-105, Page 1, Line 34
__, __ __ __.
Duplex or Photocopies NOT Acceptable

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