Form 84-115 Pass Through Entity Declaration for Electronic Filing

Ending (See Instructions) * If the corporation is filing a balance due return and the Department of Revenue does not receive full and timely payment of its tax liability the accepted and if rejected the reason(s) for the rejection This declaration is to be maintained by the ERO and provided to DOR on request Amount of Payment Remitted Electronically Amount You Owe (Form 84 105 Line 18) Check if Also Check if Self corporation will be liable for the tax liability and all applicable interest and penalties corresponding lines of the corporation's Mississippi Corporate Income & Franchise Tax Return To the best of my knowledge and belief County Code declaration and accompanying schedules and statements to the Department of Revenue (DOR) Declaration for Electronic Filing DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER (See Instructions) DECLARATION OF OFFICER (See Instructions) DO NOT MAIL THIS DOCUMENT TO THE DEPARTMENT OF REVENUE DO NOT MAIL THIS DOCUMENT TO THE DOR Duplex or Photocopies NOT Acceptable ELECTRONIC RETURN ORIGINATOR (ERO) RETAIN THIS FORM IN YOUR FILES Employed employed) address and ZIP code ERO transmitter and/or ISP an acknowledgement of receipt of transmission and an indication of whether or not the corporation's return is ERO'S ERO's Signature ERO's SSN or PTIN Firm's Name (or your's if Self For Calendar Year 2011 or Tax Year Beginning Form 84 115 11 8 1 000 Rev (05/11) I also consent to the DOR my I declare that I have reviewed the above corporation's return and that the entries on Form MS8453 C are complete and correct to the best of my IRS DECLARATION CONTROL NUMBER knowledge knowledge If I am only a collector I am not responsible for reviewing the return and only declare that this form accurately reflects the data on Mailing Address (P O Box or Street Including Rural Route) Mississippi Mississippi Taxable Income (Form 84 105 Line 5) MS8453 PTE of my knowledge and belief they are true correct and complete This Paid Preparer declaration is based on all information of which I have any originator (ERO) transmitter and/or intermediate service provider (ISP) and the amounts in Part I above agree with the amounts on the Overpayment (Form 84 105 Line 19) Paid Preparer PART I: PART II: Participation and Pub 4163 Modernized e File (MeF) Information for Authorized IRS e file Providers If I am also the Paid Preparer under Pass Through Entity penalties of perjury I declare that I have examined the above corporation's return and accompanying schedules and statements and to the best Phone No ( Preparer's Preparer's Signature Preparer's SSN or PTIN Refund (Form 84 105 Line 21) Signature of Officer State TAX RETURN INFORMATION (Round to the Nearest Dollar) the best of my knowledge and belief they are true correct and complete This declaration is based on all information of which I have any the corporation's return is true correct and complete I consent to my ERO transmitter and/or ISP sending the corporation's return this the return The corporate officer will have signed this form before I submit the return I will give the officer a copy of all forms and information Title to be filed with the Department of Revenue (DOR) and have followed all other requirements in Pub 3112 IRS e file Application and Total Income Tax (Form 84 105 Line 6) Total Payments & Credits (Form 84 105 Line 7 and Line 12) Under penalties of perjury I declare that I have examined the above corporation's return and accompanying schedules and statements and to Under the penalties of perjury I declare that I am an officer of the above corporation and that the information I have given my electronic return Use Only Zip +4