Form 84 387 11 8 2 000 (Rev 08/11)
Identification Number
m m d d y y y y
m m d d y y y y
Officer/ Agent Signature
Partnership Income Tax Withholding Voucher
State
Total Amounts From All Additional Pages
Total Estimate Payment
Total of Amounts Entered on Lines 3 Through 16
Zip +4
(Add Lines 17 and 18 Should Equal Amount of Payment / Gain
(Add Lines and Enter Total Amount on Form 84 387 Page 1 Line 18 )
(Form(s) 84 387 Page 2)
1 Total Partnership Net Gain or Profit
2 5% of Net Gain or Profit Withheld
Address
Amount of Payment
Business Name and DBA
Check or money order payable to Department of Revenue
Code2Of5InterleavedBarCode1 843871181000
Code2Of5InterleavedBarCode1 843871182000
Duplex or Photocopies NOT Acceptable
Enter the Total Amount of Tax Withheld and Remitted by Partnership for Owners / Partners Listed Below
Entered on Line 2)
Estimate Due Date
FEIN SSN
Filed on Estimate Form(s)
Form 84 387 11 8 1 000 (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
Jackson MS 39225 3075
Mail To: Department of Revenue
Mississippi
Number of Owners / Partners
or see instructions for electronic payment options
Owner / Partner Name
Ownership Percentage
P O Box 23075
Page 1
Page 2
Partnership Income Tax Withholding Voucher
Print FEIN on Check
Subtotal
Supplemental Page of
Tax Year Beginning
Tax Year Ending
Title
Total
