Form 80-108-22-3-1-000 (Rev. 08/22)
0606 0707 080 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 808 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80
0404 Mississippi 0404
0505 Page 1 0505
Adjustments And Contributions
0606 801082231000 0606
0707 2022 0707
0808 0808
0909 Taxpayer Name SSN 0909
999999999
1010XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 1010
1111 PART I: SCHEDULE A - ITEMIZED DEDUCTIONS (ATTACH FEDERAL FORM 1040 SCHEDULE A) 1111
1212In the event you filed using the standard deduction on your federal return and wish to itemize for Mississippi purposes, use Federal Form 1040 Schedule A as a worksheet 1212
1313and transfer the information from the specific lines indicated to this Schedule A. 1313
1414 1414
15151 Federal adjusted gross income from Federal Form 1040, line 11 1 9999999999 1515
1616 1616
1717 1717
18182 a Medical and dental expenses 2a 9999999999 1818
1919 b Multiply line 1 by 7.5% (.075) 2b 9999999999 1919
2020 c Medical and dental expense deduction (line 2a minus line 2b) 2c 9999999999 2020
2121 2121
2222 2222
23233 a Total taxes paid 3a 9999999999 2323
2424 b Less state income taxes (or other taxes in lieu of) 3b 9999999999 2424
2525 c Total taxes paid deduction (line 3a minus line 3b) 3c 9999999999 2525
2626 2626
2727 2727
28284 Total interest paid 4 9999999999 2828
29295 Charitable contributions 5 9999999999 2929
30306 Total casualty or theft loss (attach Federal Form 4684) 6 9999999999 3030
3131 3131
3232 3232
33337 a Other miscellaneous deductions 7a 9999999999 3333
3434 b Less Mississippi gambling losses 7b 9999999999 3434
3535 c Total other miscellaneous deductions (line 7a minus line 7b) 7c 9999999999 3535
3636 3636
3737 3737
38388 Mississippi itemized deductions (add lines 2c, 3c, 4, 5, 6, 7c); enter here and on Resident Form 80-105, 8 9999999999 3838
3939 page 1, line 14 or Non-Resident Form 80-205, page 1, line 14a 3939
4040 4040
4141 PART II: SCHEDULE B - INTEREST AND DIVIDEND INCOME (FROM FEDERAL FORM 1040, SCHEDULE B) 4141
4242 4242
43431 Interest income from all sources 1 9999999999 4343
44442 Amount of Mississippi nontaxable interest in line 1 2 9999999999 4444
45453 Total Mississippi interest (line 1 minus line 2, enter here and on Form 80-105, line 43 or Form 80-205, line 44) 3 9999999999 4545
46464 Total dividends from all sources 4 9999999999 4646
47475 Amount of Mississippi nontaxable distributions reported in line 4 5 9999999999 4747
48486 Total Mississippi dividends (line 4 minus line 5, enter here and on Form 80-105, line 44 or Form 80-205, line 45) 6 9999999999 4848
4949 4949
5050 PART III: VOLUNTARY CONTRIBUTION CHECK-OFFS (RESIDENTS ONLY) 5050
5151You may elect to voluntarily contribute all or part (at least $1) of your income tax refund to one or more of the funds listed below. Refer to the instruction booklet 80-100 (may 5151
5252be downloaded from our website at www.dor.ms.gov) for an explanation of the purpose of each of these funds and how the refund donations will be used. 5252
5353 5353
5454 Military Family Relief Fund 9999999 Wildlife Fisheries and Parks Foundation 9999999 5454
5555 Burn Care Fund 9999999 Commission for Volunteer Service Fund 9999999 5555
5656 Wildlife Heritage Fund 9999999 5656
5757 Educational Trust Fund 9999999 5757
5858 5858
5959 Enter total of check-offs here and on Form 80-105, page 1, line 33 9999999999 5959
6060 6060
6161 6161
6262 6262
6363 6363
0606 0707 008 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32Duplex33 34 35 36and37 38Photocopies39 40 41 42 43 44 45NOT46 47 48acceptable49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 808 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80