Form 84-105 Pass Through Entity Tax Return

(Composite S Corporations and Composite Partnerships Only) (For S Corporations Line 4; S Corporation Composite Line 4 Plus Line 8 (For Composite Partnerships Line 8 Only)) (From Form 84 110 Line 19) (ROUND TO NEAREST DOLLAR) Attach statement of explanation if needed COMPOSITE INCOME TAX ENTITY INFORMATION ENTITY OFFICER INFORMATION m m d d y y y y Mail Return To: DEPARTMENT OF REVENUE P O BOX 23050 JACKSON MS 39225 3050 Mississippi Mississippi MS Secretary of State ID NAICS Code Name FEIN/SSN and address of new company corporation or owner(s) Attach schedule if needed PASS THROUGH ENTITY SCHEDULE PASS THROUGH ENTITY SCHEDULE Pass Through Entity Tax Return PAYMENTS AND TAX DUE Q SUB / DISREGARDED ENTITY SCHEDULE Q SUB / DISREGARDED ENTITY SCHEDULE Supplemental Pass Through Entity Schedule Tax Year Ending (Corporation LLC Etc ) (Federal 1065) (Federal 1120 S) (If Line 12 is Larger Than Line 9; Line 12 Minus Line 9) (If Line 9 is Larger than Line 12 Add Line 13 Through Line 17 ) (Y / N) 1 If final return indicate if the company has been: Dissolved Sold/Merged Incorporated 1 Taxable Capital 10 Overpayments From Prior Year 100% Mississippi 11 Estimated Tax Payments and Payment with Extension 12 Total Payments (Line 10 Plus Line 11) 13 Net Total Franchise and/or Income Tax (Line 9 Minus Line 12) 14 Interest and Penalty on Underestimated Income Tax Payments 15 Late Payment Interest 16 Late Payment Penalty 17 Late Filing Penalty 18 TOTAL BALANCE DUE (Tax Penalty and Interest) 19 TOTAL OVERPAYMENT of Income and /or Franchise Tax 2 Franchise Tax 2 If amended return check reason 20 Overpayment CREDITED to Next Year (From Line 19) 21 Overpayment to Be REFUNDED (Line 19 Minus Line 20) 3 Franchise Tax Credit (From Form 84 401 Line 1) 3 If a partnership or LLC has a federal election been made to file as a corporation? Yes No 4 Check if the company has been audited by the IRS If the company has been audited what year(s) are involved? 4 Net Franchise Tax Due (Line 2 Minus Line 3) 5 Mississippi Net Taxable Income (From Form 84 122 Line 32) 6 Income Tax 7 Income Tax Credits (From Form 84 401 Line 3) 8 Net Income Tax Due (Line 6 Minus Line 7) 9 Total Franchise and/or Income Tax Additional Page of Address Address Address Address Amended Federal 1065 / 1120S Amended Return Business Name and DBA Business Phone Check All That Apply Check Box if Return May Be Discussed with Preparer Check One Code2Of5InterleavedBarCode1 841051281000 Code2Of5InterleavedBarCode1 841051282000 Code2Of5InterleavedBarCode1 841051283000 Code2Of5InterleavedBarCode1 841051284000 Composite Return County Code Entity Entity Name Entity Name Entity Type Entity Type Federal Audit (RAR) Fee In Lieu FEIN / SSN Final Return Form 84 105 12 8 1 000 (Rev 05/12) Form 84 105 12 8 2 000 (Rev 05/12) Form 84 105 12 8 3 000 (Rev 05/12) Form 84 105 12 8 4 000 (Rev 05/12) 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 If issuing 100 or more K 1's this return must be filed electronically See www dor ms gov for information List All Pass Through Entities in Mississippi that the S Corporation / Partnership invested in during the tax year Attach additional schedule Form 84 105 page 3 if needed List All pass through entities in Mississippi that the S Corporation / Partnership invested in during the tax year Continued from page 2 part II List all Qualified Subchapter S Subsidiaries (Q Sub) / Disregarded Entities Continued from page 2 part III List All Qualified Subchapter Subsidiaries (Q Sub) and/or Disregarded Entities Attach additional schedule Form 84 105 page 3 if needed List the Owners Officers Directors or Partners who have a responsibility in the fiscal management of the organization Minimum Tax $25 Mississippi Mississippi Correction Federal Correction Other Mississippi Operations Mississippi Operations Multistate Apportioning Multistate Direct Accounting Non Profit Officer Name and Title Officer Signature and Title Ownership Page 1 Page 2 Page 3 Page 4 Paid Preparer Address Paid Preparer Phone Paid Preparer PTIN Paid Preparer Signature PART l PART lI PART lII PART lV Partnership / LLC / LLP Percentage PTE 2012 Internet Forms Final Forms for PTE July 10 2012 S Corporation S CORPORATION FRANCHISE TAX See instructions for electronic payment options or attach Check or Money Order for balance due State Tax Year Beginning Total Number of Mississippi K 1's Zip Code Zip+4