Form 84-380 Non-Resident Income Tax Agreement

m m d d y y y y Non Resident Income Tax Agreement State Tax Year Beginning This agreement shall be binding upon my heirs representatives assigns successors executors and administrators Zip +4 (1) To timely file a Mississippi Non Resident Income Tax Return (Form 80 205) and make timely payment of all taxes imposed by Mississippi upon my pro rata share of income/loss in the above named S Corporation for the year above and all subsequent taxable years for which I am a shareholder (2) To be subject to personal jurisdiction in this state for purposes of the collection of income taxes together with related interest and penalties imposted on the shareholder by this state with respect to the income of the S corporation Address AGREEMENT Business Name Do not file this agreement with the S Corporation Tax Return Form 84 380 12 8 1 000 (Rev 05/12) I further certify that I am or have been a shareholder of said corporation during its taxable year Mississippi Name of Taxpayer Pursuant to Miss Code Ann Section 27 8 19(4) I hereby covenant and agree: Retain this agreement in your permanent tax files Signature of Non Resident Shareholder Tax Year Ending This form may be reproduced