Form 80-340-12 -8-1-000 - Mississippi Affidavit In Support Of Reservation Indian Income Exclusion From Mississippi State Income Taxes

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Form 80-340-12 -8-1-000 (Rev. 5/12)
Mississippi
Affidavit In Support Of
Reservation Indian Income Exclusion From
Mississippi State Income Taxes
Tax Year _________
Middle Initial
YOU MUST ENTER SSN
First Name
Taxpayer Last Name
__ __ __ - __ __ - __ __ __ __
Spouse First Name
Middle Initial
Spouse Last Name
SSN
Spouse
__ __ __ - __ __ - __ __ __ __
Mailing Address (Number & Street, Including Rural Route)
SSN
State
Zip
City
__ __
Residence County Code - See Instructions
Indian Status (Check One)
(a) I am a Mississippi Choctaw Indian.
Yes
No
(b) I am a member or am eligible for membership in an
OR
Indian Tribe other than the Mississippi Band of Choctaws.
Yes
No
Name of Tribe
Reservation Residency
(a) During
I lived on the Mississippi Choctaw Indian Reservation for (Check one box ONLY below.)
The entire year.
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
(Circle months lived on reservation.)
I did not live on the Choctaw Reservation during
(b) My place(s) of residence on the Choctaw Reservation during
was (were) located on (Check one or more boxes below.)
A tribal housing site lease.
A Choctaw housing authority house site.
A BIA dormitory or house.
Reservation Income
(a) During the months I lived on the Choctaw Reservation in
, I earned the following income from work on the Choctaw
Reservation
.
(b) My employer(s) for my on-reservation work during
was (were) the (Check one or more boxes below.)
Mississippi Band of Choctaw Indians.
Bureau of Indian Affairs.
Indian Health Service, USPHS.
Other:
Name of Employer
Employer Phone
Employer Address
I 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 McClanahan 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. 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.
Signature
Date
Preparer Signature
Date
Mail this form separately from your State Tax Return to:
Department of Revenue
P.O. Box 1033
Jackson, MS 39215
Duplex or Photocopies NOT Acceptable

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