Form 80-340 "Affidavit for Reservation Indian Income Exclusion From Mississippi State Income Taxes" - Mississippi

What Is Form 80-340?

This is a legal form that was released by the Mississippi Department of Revenue - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2018;
  • The latest edition provided by the Mississippi Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 80-340 by clicking the link below or browse more documents and templates provided by the Mississippi Department of Revenue.

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Download Form 80-340 "Affidavit for Reservation Indian Income Exclusion From Mississippi State Income Taxes" - Mississippi

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Reset Form
Form 80-340-18-8-1-000 (Rev. 08/18)
Print Form
Mississippi
Affidavit for Reservation Indian
Income Exclusion From Mississippi State Income Taxes
Taxpayer First Name
Initial
Last Name
Tax Year
Spouse First Name
Initial Last Name
SSN
Mailing Address (Number and Street, Including Rural Route)
Spouse SSN
City
State
Zip
County Code
INDIAN STATUS
(CHECK ONE)
Yes
No
(a) I am a Mississippi Choctaw Indian.
Yes
No
(b) I am a member or am eligible for membership in an Indian Tribe other than the Mississippi Band of Choctaws.
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
was (were) located on (check one or more boxes below)
(b) My place(s) of residence on the Choctaw Reservation during
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 with your state tax return to: P.O. Box 1033, Jackson, MS 39215
Reset Form
Form 80-340-18-8-1-000 (Rev. 08/18)
Print Form
Mississippi
Affidavit for Reservation Indian
Income Exclusion From Mississippi State Income Taxes
Taxpayer First Name
Initial
Last Name
Tax Year
Spouse First Name
Initial Last Name
SSN
Mailing Address (Number and Street, Including Rural Route)
Spouse SSN
City
State
Zip
County Code
INDIAN STATUS
(CHECK ONE)
Yes
No
(a) I am a Mississippi Choctaw Indian.
Yes
No
(b) I am a member or am eligible for membership in an Indian Tribe other than the Mississippi Band of Choctaws.
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
was (were) located on (check one or more boxes below)
(b) My place(s) of residence on the Choctaw Reservation during
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 with your state tax return to: P.O. Box 1033, Jackson, MS 39215