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Form 80-340-22-8-1-000 (Rev. 10/22)
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                                                                         Mississippi
                                                           Affidavit for Reservation Indian
                                   Income Exclusion From Mississippi State Income Taxes
Taxpayer First Name                               Initial  Last Name                                                                            Tax Year

Spouse First Name                                 Initial  Last Name                                            SSN

Mailing Address (Number and Street, Including Rural Route)                                                      Spouse SSN

City                                              State    Zip                             County Code

INDIAN STATUS    (CHECK ONE)

(a) I am a Mississippi Choctaw Indian.                                                  Yes           No

(b) I am a member or am eligible for membership in an Indian Tribe other than the Mississippi Band of Choctaws.                                 Yes      No

Name of Tribe

RESERVATION RESIDENCY

(a) During                   I lived on the Mississippi Choctaw Indian Reservation for... (check one box ONLY below)

          The entire year
          Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec                    (Circle months lived on reservation)
          I did not live on the Choctaw Reservation during

(b) My place(s) of residence on the Choctaw Reservation during                          was (were) located on (check one or more boxes below)

          A tribal housing site lease
          A Choctaw housing authority house site
          A BIA dormitory or house

RESERVATION INCOME

(a) During the months I lived on the Choctaw Reservation in                     , I earned the following income from work on the Choctaw Reservation

(b) My employer(s) for my on-reservation work during                        was (were) the... (check one or more boxes below)

          Mississippi Band of Choctaw Indians
          Bureau of Indian Affairs
          Indian Health Service, USPHS
          Other

Name of Employer                                                                              Employer Phone

Employer Address

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).  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.

Signature                                                                                            Date

Preparer Signature                                                                                   Date

                                                           Mail this form to:  P.O. Box 1033, Jackson, MS 39215