Form 84-105-12-8-1-000 - Pass-Through Entity Tax Return

Form 84-105-12-8-1-000 - Pass-Through Entity Tax Return - 2012 Page 2

Mississippi

Form 84-105-12-8-2-000 (Rev. 05/12)

Pass-Through Entity Tax Return

2012

841051282000

Page 2

FEIN

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PART l

ENTITY INFORMATION

1. If final return, indicate if the company has been:

Dissolved

Sold/Merged

Incorporated

•

Name, FEIN/SSN and address of new company, corporation or owner(s). Attach schedule if needed.

FEIN / SSN

2. If amended return, check reason.

Mississippi Correction

Federal Correction

Other

Amended Federal 1065 / 1120S,

Attach statement of explanation, if needed.

Federal Audit (RAR)

3. If a partnership or LLC, has a federal election been made to file as a corporation?

Yes

4. Check if the company has been audited by the IRS.

If the company has been audited, what year(s) are involved?

PART lI

PASS-THROUGH ENTITY SCHEDULE

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.

Entity Type

Address

Entity Name

FEIN

(Corporation, LLC, Etc...)

PART lII

Q-SUB / DISREGARDED ENTITY SCHEDULE

List All Qualified Subchapter Subsidiaries (Q-Sub) and/or Disregarded Entities. Attach additional schedule, Form 84-105, page 3, if needed.

Mississippi Operations

Entity Name

Address

FEIN

(Y / N)

PART lV

ENTITY OFFICER INFORMATION

List the Owners, Officers, Directors or Partners who have a responsibility in the fiscal management of the organization.

Ownership

SSN

Address

Officer Name and Title

Percentage

Check Box if Return May Be Discussed with Preparer

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.

Date

Business Phone

Officer Signature and Title

Date

Paid Preparer Signature

Paid Preparer Address

Zip Code

Paid Preparer PTIN

City

State

Paid Preparer Phone

Mail Return To