Form 80-491-12-8-1-000 (Rev. 5/12)
MS
Mississippi
Individual Income Tax Statement of
804911281000
Additional Dependents
2012
YOU MUST ENTER SSN
Middle Initial
First Name
Taxpayer Last Name
Middle Initial
__ __ __ - __ __ - __ __ __ __
Spouse First Name
Spouse Last Name
SSN
Spouse
__ __ __ - __ __ - __ __ __ __
Mailing Address (Number & Street, Including Rural Route)
SSN
State
Zip
City
__ __
Residence County Code - See Instructions
A dependent is a relative or other person who qualifies for federal income tax purposes as a dependent of the taxpayer. Enter the dependent's name
(Column A), the dependent's relationship to taxpayer (Column B), and the dependent's Social Security number (Column C).
(B) Dependents
(A) Dependent's Name
(C) Dependent's SSN
Enter C for child, P for parent and R for relative
1.
__ __ __ - __ __ - __ __ __ __
_________________________________
____
2.
_________________________________
____
__ __ __ - __ __ - __ __ __ __
3.
__ __ __ - __ __ - __ __ __ __
_________________________________
____
4.
_________________________________
____
__ __ __ - __ __ - __ __ __ __
5.
_________________________________
____
__ __ __ - __ __ - __ __ __ __
6.
_________________________________
____
__ __ __ - __ __ - __ __ __ __
7.
____
_________________________________
__ __ __ - __ __ - __ __ __ __
8.
__ __ __ - __ __ - __ __ __ __
_________________________________
____
9.
_________________________________
____
__ __ __ - __ __ - __ __ __ __
10.
_________________________________
____
__ __ __ - __ __ - __ __ __ __
11.
_________________________________
____
__ __ __ - __ __ - __ __ __ __
12.
_________________________________
____
__ __ __ - __ __ - __ __ __ __
13.
__ __ __ - __ __ - __ __ __ __
____
_________________________________
14.
_________________________________
____
__ __ __ - __ __ - __ __ __ __
15.
_________________________________
____
__ __ __ - __ __ - __ __ __ __
Duplex and Photocopies NOT Acceptable