Form 83-105-10-8-1-000 - Corporate Income And Franchise Tax Return - 2010 Page 2

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Mississippi
Form 83-105-10-8-2-000 (Rev. 05/10)
Corporate Income and Franchise Tax Return
2010
Page 2
831051082000
Corporate Information
1. DBA
2. County locations in Mississippi
3. Principal business activity in Mississippi
4. Principal business activity everywhere
5. Principal product or service in Mississippi
6. Principal product or service everywhere
7. Contact person for this return
8. Contact person's location and phone
(
)
9. If final return, check reason and enter date effective:
Date
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Dissolving Mississippi Corporation
Withdrawing Non-Mississippi Corporation from State
Sold MS Assets
Merged
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Other :
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If you checked Sold or Merged, provide the following:
New company or owner's name and address
FEIN
Phone
(
)
Former owner's forwarding address
Phone
(
)
. . .
. . .
10a.
Is this corporation a partner/member in a partnership, LLP or LLC doing business in Mississippi?
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Yes
No
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If Yes, attach Mississippi Form K-1(s).
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10b.
Is this corporation the owner/member of a single member LLC doing business in Mississippi?
Yes
No
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Yes
No
11.
Has the corporation filed amended federal returns in the last three years?
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If Yes, list years.
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Yes
No
12.
Has the IRS made any changes to your taxable income in the last three years?
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If Yes, list years.
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If Line 11 and/or Line 12 was checked "Yes", has the corporation filed Mississippi amended returns for all years for
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Yes
No
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which amended Federal return(s) were filed or changes to taxable income were made by the IRS?
List of Officers - This Schedule MUST be Completed
President: Name and Home Address
Social Security Number
Ownership Percentage
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Vice President: Name and Home Address
Social Security Number
Ownership Percentage
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Salary
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Treasurer: Name and Home Address
Social Security Number
Ownership Percentage
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Secretary: Name and Home Address
Social Security Number
Ownership Percentage
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Mail Return To: Department of Revenue P.O. Box 23050 Jackson, MS 39225-3050

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