Residence County Code See Instructions
YOU MUST ENTER SSN
(A) Dependent's Name
(B) Dependents Enter C for child P for parent and R for relative
(C) Dependent's SSN
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)
Additional Dependents
Code2Of5InterleavedBarCode4 804911281000
Duplex and Photocopies NOT Acceptable
First Name
Form 80 491 12 8 1 000 (Rev 5/12)
Individual Income Tax Statement of
Mailing Address (Number & Street Including Rural Route)
Middle Initial
Mississippi
Spouse
Spouse First Name
Spouse Last Name
State
Taxpayer Last Name
