Form 80-491-17-8-1-000 - Mississippi Individual Income Tax Statement Of Additional Dependents - 2017

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Form 80-491-17-8-1-000 (Rev. 10/17)
Print Form
Mississippi
Individual Income Tax Statement of
804911781000
Additional Dependents
2017
Taxpayer First Name
Initial
Last Name
SSN
Initial Last Name
Spouse First Name
Spouse SSN
Mailing Address (Number and Street, Including Rural Route)
City
State
Zip
County Code
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) DEPENDENT
(A) DEPENDENT'S NAME
(C) DEPENDENT'S SSN
Enter "C" for child, "P" for parent and "R" for relative
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Duplex and Photocopies NOT Acceptable

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