Form 80-115 Declaration for E-File

Residence County Code See Instructions YOU MUST ENTER SSN (Preparer Address if Self Employed) (Round to the Nearest Dollar) 1 Mississippi Taxable Income 1 Routing Number 2 Account Number 2 Total Mississippi Tax 3 Mississippi Tax Payments & Credits 3 Type of Account 4 Refund 5 Amount You Owe Check If: Checking DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER DECLARATION OF TAXPAYER DO NOT Mail this Document to the Mississippi Department of Revenue Duplex or Photocopies NOT Acceptable Electronic Return Employer Identification Number or PTIN ERO Signature ERO USE ONLY Firm Name & Address First Name For Electronic Filing Form 80 115 12 8 1 000 Rev (7/12) Individual Income Tax Declaration IRS DECLARATION CONTROL NUMBER Mailing Address (Number & Street Including Rural Route) Middle Initial Mississippi MS8453 My request for direct deposit of my refund includes my authorization for the Mississippi Department of Revenue to furnish my financial institution with my routing number account number account type and social security number to insure my refund is properly deposited Originator (ERO) Paid Preparer Paid Preparer Signature Paid Preparer Use Only PART I: PART I: TAX RETURN INFORMATION PART II: DIRECT DEPOSIT PART III: PART IV: Savings Self Employed Signature of Spouse Signature of Taxpayer Social Security Number or PTIN Spouse Spouse First Name Spouse Last Name State Taxpayer Last Name Under penalties of perjury I declare that I have compared the information contained on my income tax return with the information I have provided to my electronic return originator and that the amounts described in Part I above agree with the amounts shown on the corresponding lines of my Mississippi income tax return To the best of my knowledge and belief my return is true correct and complete This declaration is to be maintained by the electronic return originator and provided to Mississippi Department of Revenue on request Under penalties of perjury I declare that I have reviewed the above taxpayer's return and that the entries on this form are complete and correctly represented to the best of my knowledge I have obtained the taxpayer's signature and will maintain this return for the Mississippi Department of Revenue as part of my permanent records Upon written request I will furnish this return to the Mississippi Department of Revenue I have provided the taxpayer with a copy of all forms and information to be filed electronically with the Mississippi Department of Revenue and have followed all other requirements described in the Mississippi Handbook for Electronic Filers and any additional requirements specified by the Mississippi Department of Revenue If I am the paid preparer under penalties of perjury I declare that I have examined this return and accompanying schedules and statements and to the best of my knowledge and belief they are true correct and complete Declaration of preparer is based on all information of which preparer has any knowledge