Form 80-491-22-3-1-000 (Rev. 07/22)
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0404 Mississippi 0404
0505 Individual Income Tax Statement of 0505
0606 804912231000 0606
0707 Additional Dependents 0707
0808 2022 0808
0909 0909
1010 Taxpayer First Name Initial Last Name SSN 1010
999999999
1111XXXXXXXXXXXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXXX 1111
1212 Spouse First Name Initial Last Name Spouse SSN 1212
999999999
1313XXXXXXXXXXXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXXX 1313
1414 Mailing Address (Number and Street, Including Rural Route) 1414
1515X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X 1515
1616 City State Zip County Code 1616
1717XXXXXXXXXXXXXXXXXXXXX XX 99999 99 1717
1818 1818
1919A dependent is a relative or other person who qualifies for federal income tax purposes as a dependent of the taxpayer. Enter the dependent's name 1919
2020(Column A), the dependent's relationship to taxpayer (Column B), and the dependent's social security number (Column C). 2020
2121 2121
2222 (A) DEPENDENT'S NAME (B) DEPENDENT (C) DEPENDENT'S SSN 2222
2323 Enter "C" for child, "P" for parent and "R" for relative 2323
2424 2424
25251 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 2525
2626 2626
27272 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 2727
2828 2828
29293 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 2929
3030 3030
31314 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 3131
3232 3232
33335 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 3333
3434 3434
35356 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 3535
3636 3636
3737 7 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 3737
3838 3838
3939 8 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 3939
4040 4040
41419 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 4141
4242 4242
4343 10 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 4343
4444 4444
454511 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 4545
4646 4646
474712 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 4747
4848 4848
494913 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 4949
5050 5050
5151 14 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 5151
5252 5252
535315 XXXXXXXXXXXXXXXXXXXXXXXXXX X 999999999 5353
5454 5454
5555 5555
5656 5656
5757 5757
5858 5858
5959 5959
6060 6060
6161 6161
6262 6262
6363 Duplex and Photocopies NOT Acceptable 6363
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