Form 80-340-22-3-1-000 (Rev. 07/22)
0606 0707 08009 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 0404
Mississippi
0505 Affidavit for Reservation Indian 0505
0606 Income Exclusion From Mississippi State Income Taxes 0606
0707 0707
0808 Taxpayer First Name Initial Last Name Tax Year 0808
9999
0909XXXXXXXXXXXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXXX 0909
1010 Spouse First Name Initial Last Name SSN 1010
999999999
1111XXXXXXXXXXXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXXX 1111
1212 Mailing Address (Number and Street, Including Rural Route) Spouse SSN 1212
999999999
1313X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X 1313
1414 City State Zip County Code 1414
1515XXXXXXXXXXXXXXXXXXXXX XX 99999 99 1515
1616 1616
1717 INDIAN STATUS (CHECK ONE) 1717
1818 1818
1919(a) I am a Mississippi Choctaw Indian. X Yes X No 1919
2020 2020
2121(b) I am a member or am eligible for membership in an Indian Tribe other than the Mississippi Band of Choctaws. X Yes X No 2121
2222 2222
2323 Name of Tribe XXXXXXXXXXXXXXXXXXXXX 2323
2424 2424
2525 RESERVATION RESIDENCY 2525
2626 2626
2727(a) During 9999 I lived on the Mississippi Choctaw Indian Reservation for... (check one box ONLY below) 2727
2828 2828
2929 X The entire year 2929
3030 X Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec (Circle months lived on reservation) 3030
3131 X I did not live on the Choctaw Reservation during 9999 3131
3232 3232
3333(b) My place(s) of residence on the Choctaw Reservation during 9999 was (were) located on (check one or more boxes below) 3333
3434 3434
3535 X A tribal housing site lease 3535
3636 X A Choctaw housing authority house site 3636
3737 X A BIA dormitory or house 3737
3838 3838
3939 RESERVATION INCOME 3939
4040 4040
4141(a) During the months I lived on the Choctaw Reservation in 9999 , I earned the following income from work on the Choctaw Reservation 4141
4242 X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9 4242
4343 4343
4444(b) My employer(s) for my on-reservation work during 9999 was (were) the... (check one or more boxes below) 4444
4545 4545
4646 X Mississippi Band of Choctaw Indians 4646
4747 X Bureau of Indian Affairs 4747
4848 X Indian Health Service, USPHS 4848
4949 X Other 4949
5050 5050
5151Name of Employer Employer Phone 5151
5252X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X (999)999-9999 5252
5353Employer Address 5353
5454X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X XXXXXXXXXXXXXXXXXXXXX XX 99999 5454
5555I 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 5555
5656McClanahan 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. 5656
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.
5757 5757
5858 5858
5959Signature Date 5959
6060 6060
6161Preparer Signature Date 6161
6262 6262
6363 Mail this form to: P.O. Box 1033, Jackson, MS 39215 6363
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