Form 80-340 Reservation Indian Exclusion

I earned the following income from work on the Choctaw Residence County Code See Instructions YOU MUST ENTER SSN (a) During (a) During the months I lived on the Choctaw Reservation in (a) I am a Mississippi Choctaw Indian (b) I am a member or am eligible for membership in an (b) My employer(s) for my on reservation work during (b) My place(s) of residence on the Choctaw Reservation during (Check one or more boxes below ) (Check One) (Circle months lived on reservation ) A BIA dormitory or house A Choctaw housing authority house site A tribal housing site lease Affidavit In Support Of Bureau of Indian Affairs Department of Revenue P O Box 1033 Jackson MS 39215 Duplex or Photocopies NOT Acceptable Employer Address Employer Phone First Name Form 80 340 12 8 1 000 (Rev 5/12) I did not live on the Choctaw Reservation during I do hereby claim that the above described earned income falls outside the taxing jurisdiction of the State of Mississippi on the basis of the legal principles established in McClanahan vs Arizona Tax Commission 411 U S 164 (1973) I lived on the Mississippi Choctaw Indian Reservation for (Check one box ONLY below ) Indian Health Service USPHS Indian Status Indian Tribe other than the Mississippi Band of Choctaws Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Mail this form separately from your State Tax Return to: Mailing Address (Number & Street Including Rural Route) Middle Initial Mississippi Mississippi Band of Choctaw Indians Mississippi State Income Taxes Name of Employer Name of Tribe Other: Preparer Signature Reservation Reservation Income Reservation Indian Income Exclusion From Reservation Residency Signature Spouse Spouse First Name Spouse Last Name State Tax Year Taxpayer Last Name The entire year THIS FORM MUST BE SIGNED If someone else completed this form both of you must sign the form Under penalties of perjury I declare that I have examined this form and to the best of my knowledge and belief this form is true correct and complete was (were) located on (Check one or more boxes below ) was (were) the