Form 80-205-22-3-1-000 (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 39Mississippi40 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 Non-Resident / Part-Year Resident 0404
0505 0505
0606 802052231000 Individual Income Tax Return Amended 0606
2022 X
0707 0707
0808X Non-Resident X Part-Year, Tax Year Beginning 99999999 and Ending 99999999 0808
0909 0909
1010 Taxpayer First Name Initial Last Name SSN 1010
999999999
1111XXXXXXXXXXXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXXX Spouse SSN 999999999 1111
1212 Spouse First Name Initial Last Name 1212
1313XXXXXXXXXXXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXXX 1 X Married - Combined or Joint Return ($12,000)1313
1414 Mailing Address (Number and Street, Including Rural Route) 2 X Married - Spouse Died in Tax Year ($12,000)1414
1515X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X 3 X Married - Filing Separate Returns ($12,000) 1515
1616 City State Zip County Code 4 X Head of Family ($8,000) 1616
1717XXXXXXXXXXXXXXXXXXXXX XX 99999 99 5 X Single ($6,000) 1717
1818 EXEMPTIONS 1818
1919 1919
2020Dependents (in column B, enter "C" for child, "P" for parent or "R" for relative) 8 X Taxpayer Age 65 or Over X Spouse Age 65 or Over 2020
21216 (A) Name (B) (C) Dependent SSN X Taxpayer Blind X Spouse Blind 2121
2222 XXXXXXXXXXXXXXXXXX X 999999999 2222
2323 XXXXXXXXXXXXXXXXXX X 999999999 9 Total dependents line 7 plus number of boxes checked line 8 99 2323
2424 XXXXXXXXXXXXXXXXXX X 999999999 10 Line 9 x $1,500 10 9999999999 2424
2525 XXXXXXXXXXXXXXXXXX X 999999999 11 Enter filing status exemption 11 9999999999 2525
26267 Total number of dependents (from line 6 and Form 80-491) 99 12 Total (line 10 plus line 11) 12 9999999999 2626
2727 2727
2828 PRORATION (COMPLETE PAGE 2 BEFORE PROCEEDING FURTHER) 2828
2929 13a Mississippi adjusted gross income 14a Standard or itemized deductions 15a Exemptions (from line 12; if married 2929
3030 9999999999 9999999999 filing separate, use 1/2 amount) 3030
3131 bAdjusted gross income from all sources bMississippi deductions 9999999999 3131
3232 9999999999 (line 14a multiplied by line 13c) bMississippi exemption 3232
3333 cLine 13a divided by line 13b 9999999999 (line 15a multiplied by line 13c) 3333
3434 99.9999 9999999999 3434
3535 3535
MISSISSIPPI INCOME TAX Column A (Taxpayer) Column B (Spouse)
3636 3636
373716 Mississippi adjusted gross income (from page 2, line 67 or line 68) 16A 9999999999 16B 9999999999 3737
383817 Deductions (from line 14b; if itemized, attach Form 80-108) 17A 9999999999 17B 9999999999 3838
393918 Exemptions (from line 15b) 18A 9999999999 18B 9999999999 3939
404019 Mississippi taxable income (line 16 minus line 17 and line 18) 19A 9999999999 19B 9999999999 4040
414120 Income tax due (from Schedule of Tax Computation, see instructions) 20 9999999999 4141
424221 Credit for tax paid on an electing Pass-Through Entity Tax Return (from Form 80-161, line 3d) 21 9999999999 4242
434322 Other credits (from Form 80-401, line 1) 22 9999999999 4343
444423 Net income tax due (line 20 minus line 21 and line 22) 23 9999999999 4444
454524 Consumer use tax (see instructions) 24 9999999999 4545
464625 Catastrophe savings tax (see instructions) 25 9999999999 4646
474726 Total Mississippi income tax due (line 23 plus line 24 and line 25) 26 9999999999 4747
484827 Mississippi income tax withheld (complete Form 80-107) 27 9999999999 4848
494928 Estimated tax payments, extension payments and/or amount paid on original return 28 9999999999 4949
505029 Refund received and/or amount carried forward from original return (amended return only) 29 9999999999 5050
515130 Total payments (line 27 plus line 28 minus line 29) 30 9999999999 5151
525231 Overpayment (if line 30 is more than line 26, subtract line 26 from line 30; if zero, skip to line 36) 31 9999999999 5252
535332 Interest and penalty (from Form 80-320, line 11 and/or line 12) 32 9999999999 5353
545433 Adjusted overpayment (line 31 minus line 32) 33 9999999999 5454
555534 Overpayment to be applied to next year estimated tax account X Farmers or Fishermen 34 9999999999 5555
565635 Overpayment refund (line 33 minus line 34) (see instructions) REFUND 5656
35 9999999999
5757 X Direct Deposit Request 5757
(check box and go to page 3)
5858 5858
595936 Balance due (if line 26 is more than line 30, subtract line 30 from line 26) BALANCE DUE 36 9999999999 5959
606037 Interest and penalty (from Form 80-320, line 19) 37 9999999999 6060
616138 Total due (line 36 plus line 37) AMOUNT YOU OWE 38 9999999999 6161
6262 Installment Agreement Request 6262
6363 X (see instructions for eligibility; attach Form 71-661) 6363
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
PLEASE SIGN THIS TAX RETURN ON THE BOTTOM OF PAGE 3