Form 83-105 Corporate Income and Franchise Tax Return

(Enter FEIN of Reporting Corporation) (From Form 83 110 Line 19) (From Form 83 122 Line 30 or Form 83 310 Line 5 Column C) (From Form 83 401 Line 1) (From Form 83 401 Line 3 or Form 83 310 Line 5 Column B) (If Line 9 is Larger Line 12 Add Line 13 Through Line 17 ) (Line 10 Plus Line 11) (Line 2 Minus Line 3) (Line 4 Plus Line 8) (Line 6 Minus Line 7) (Line 9 Minus Line 12) (ROUND TO NEAREST DOLLAR) Address Amended Return 100% Mississippi Check All That Apply Combined Income Tax Return Corporate Income and Franchise Tax Return Corporate Income and Franchise Tax Return Final Return Multistate Apportioning FRANCHISE TAX INCOME TAX m m d d y y y y Mail Return To: DEPARTMENT OF REVENUE P O BOX 23050 JACKSON MS 39225 3050 Mississippi Mississippi Officer Name and Title PAYMENTS AND TAX DUE State SUPPLEMENTAL CORPORATE AFFILIATION SCHEDULE Tax Year Beginning Tax Year Ending Yes If Yes under what symbol? No Zip +4 (From Form 83 305 Line 19) (From Line 19) (If Line 12 is Larger Than Line 9; Line 9 Minus Line 12) (Line 19 Minus Line 20) 1 Is this a publicly traded corporation? 1 Taxable Capital 10 Overpayments From Prior Year 11 Estimated Tax Payments and Payment with Extension 12 Total Payments 13 Net Total Franchise and Income Tax 14 Interest and Penalty on Underestimated Income Tax Payments 15 Late Payment Interest 16 Late Payment Penalty 17 Late Filing Penalty 2 Franchise Tax 2 If final return enter reason and date effective: Date 3 Franchise Tax Credit 3 If the corporation has been sold or merged complete the following: Name address and FEIN of the new existing corporation: 4 Net Franchise Tax Due 5 Mississippi Net Taxable Income 6 Income Tax 7 Income Tax Credits 8 Net Income Tax Due 831051181000 831051182000 831051183000 831051184000 9 Total Franchise and Income Tax Additional Page of Address Address Attach Payment Voucher Form 83 300 with Check or Money Order for Balance Due Business Phone Check Box if Return May Be Discussed with Preparer CORPORATE AFFILIATION SCHEDULE CORPORATE INFORMATION CORPORATE OFFICER INFORMATION County Code NAICS Code Entity Name Entity Name Entity Type Entity Type Fee In Lieu Form 83 105 11 1 000 (Rev 08/11) Form 83 105 11 8 2 000 (Rev 08/11) Form 83 105 11 8 3 000 (Rev 08/11) Form 83 105 11 8 4 000 (Rev 08/11) I declare under penalties of perjury that I have examined this return and accompanying schedules and statements and to the best of my knowledge and belief this is a true correct and complete return Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge Legal Name and DBA List all entities owned by and affiliated with the corporation Continued from page 2 part III List all entities owned by and affiliated with the corporation See page 2 for additional schedule if needed List the owners officers directors or partners who have a responsibility in the fiscal management of the organization Attach schedule if needed Minimum Income Tax Penalty $100 Minimum Tax $25 MS Secretary of State ID Multistate Direct Accounting Officer Signature and Title or See Instructions for Electronic Payment Options Overpayment CREDITED to Next Year Overpayment to Be REFUNDED Ownership Page 2 Page 3 Page 4 Paid Firm Identification Number Paid Preparer Address Paid Preparer PTIN Paid Preparer Signature PART l PART lI PART lII Percentage Preparer Phone TOTAL BALANCE DUE (Tax Penalty and Interest) Total OVERPAYMENT of Income and Franchise Tax