Form 84-387 Partnership Income Tax Withholding Voucher

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