Form 80-491 Additional Dependents

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