Form 80-401-22-3-1-000 (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 0505
Tax Credit Summary Schedule
0606 804012231000 0606
0707 2022 0707
0808 (* Carryover Not Available) 0808
0909 SSN 999999999 0909
1010 1010
1111 FEIN 999999999 1111
1212 1212
1313 TAX CREDIT CODES 1313
1414 CODE CREDIT CODE CREDIT 1414
1515 02 Premium Retaliatory 24 Alternative Energy Jobs 1515
1616 03 Finance Company Privilege 25 Child Adoption 1616
1717 05 Jobs Tax 26 Historic Structure Rehabilitation (Attach Statement) 1717
1818 06 National or Regional Headquarters 27 Long Term Care 1818
1919 07 Research and Development Skills 28 New Markets 1919
2020 08 Employer Child / Dependent Care 29 Biomass Energy Investment 2020
2121 10 Reforestation 30 Wildlife Land Use 2121
2222 11 Gambling License Fee 31 Prekindergarten Credit 2222
2323 12 Financial Institution Jobs 32 Headquarters Relocation Credit 2323
2424 13 Mississippi Revenue Bond Service 34 Qualifying Charitable Contribution Credit Approved by DOR 2424
2525 14 Ad Valorem Inventory 35 Qualifying Foster Care Charitable Credit Approved by DOR 2525
2626 15 Export Port Charges 36 Business Contributions to Eligible Charitable Organizations 2626
2727 16 Insurance Guaranty 37 Endowment Fund Charitable Credit 2727
2828 17 Import Credit 38 Inland Water Transportation 2828
2929 18 Land Donation 39 Pregnancy Resource Charitable Contribution Credit 2929
3030 19 Broadband Technology 40 Railroad Infrastructure Tax Credit 3030
3131 21 Brownfield Credit 41 Blood Donation 3131
3232 22 Airport Cargo Charges 50 Bank Share 3232
3333 23 Manufacturing Investment Tax Credit 3333
3434 3434
3535 INCOME TAX CREDITS 3535
3636 A B C D E F G 3636
3737 CREDIT 3737
3838 CODE CREDIT CREDIT RECEIVED CREDIT CREDIT USED CREDIT EXPIRED CARRYOVER 3838
3939 EARNED THIS FROM CARRYOVER THIS YEAR THIS YEAR AVAILABLE 3939
YEAR PASS-THROUGH FROM PRIOR FOR NEXT
4040 ENTITY YEAR YEAR 4040
4141 (B+C+D-E-F) 4141
4242 4242
4343 99 9999999999 9999999999 9999999999 9999999999 9999999999 9999999999 4343
4444 4444
4545 99 9999999999 9999999999 9999999999 9999999999 9999999999 9999999999 4545
4646 4646
4747 99 9999999999 9999999999 9999999999 9999999999 9999999999 9999999999 4747
4848 4848
4949 99 9999999999 9999999999 9999999999 9999999999 9999999999 9999999999 4949
5050 5050
5151 1 9999999999 5151
1 Total income tax credit used this year (total column E; enter on Form 80-105, line 20
5252 or Form 80-205, line 22) 5252
5353 5353
54542 Total income tax credit available for next year (total column G) 2 9999999999 5454
5555 5555
56563 If code 25 is selected, enter adoptee SSN(s) here 999999999 5656
5757 5757
5858 999999999 5858
5959 5959
60604 If code 34, 35, 36 or 39 is selected, enter name of charitable organization X9X9X9X9X9X9X9X9X9X9 6060
6161 (attach statement if needed) 6161
6262 X9X9X9X9X9X9X9X9X9X9 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