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Form 84-115-13-8-1-000 Rev. (09/13)
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Mississippi
MS8453-PTE
Pass - Through Entity Declaration for Electronic Filing
2013
Tax Year Beginning
Tax Year Ending
m m
d d
y y y y
m m
d d
y y y y
DO NOT MAIL THIS DOCUMENT
FEIN
TO THE DEPARTMENT OF REVENUE
Legal Name and DBA
Address
City
State
Zip +4
County Code
PART I: TAX RETURN INFORMATION
(ROUND TO THE NEAREST DOLLAR)
.
1 Mississippi taxable income (Form 84-105, line 5)
1
00
.
2 Total income tax (Form 84-105, line 6)
2
00
.
3 Total payments & credits (Form 84-105, line 7 and line 12)
3
00
.
4 Amount you owe (Form 84-105, line 18)
4
00
.
5 Overpayment (Form 84-105, line 19)
5
00
.
6 Refund (Form 84-105, line 21)
6
00
.
7
7 Amount of payment remitted electronically
00
* If the pass-through entity is filing a balance due return and the Department of Revenue does not receive full and timely payment of its tax liability,
the pass-through entity will be liable for the tax liability and all applicable interest and penalties.
PART II: DECLARATION OF OFFICER
Under the penalties of perjury, I declare that I am an officer of the above pass-through entity and that the information I have given my electronic return originator (ERO),
transmitter, and/or intermediate service provider (ISP) and the amounts in Part I above agree with the amounts on the corresponding lines of the pass-through entity's
Mississippi Pass-Through Entity Tax Return. To the best of my knowledge and belief, the pass-through entity's return is true, correct and complete. I consent to my ERO,
transmitter, and/or ISP sending the pass-through entity's return, this declaration, and accompanying schedules and statements to the Department of Revenue (DOR). I also
consent to the DOR my ERO, transmitter, and/or ISP an acknowledgement of receipt of transmission and an indication of whether or not the pass-through entity's return is
accepted, and, if rejected, the reason(s) for the rejection. This declaration is to be maintained by the ERO and provided to DOR on request.
Sign
Signature of Officer
Date
Title
Here
PART lll: DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER
I declare that I have reviewed the above pass-through entity's return and that the entries on Form MS8453-PTE are complete and correct to the best of my knowledge. If I am
only a collector, I am not responsible for reviewing the return and only declare that this form accurately reflects the data on the return. The corporate officer will have signed
this form before I submit the return. I will give the officer a copy of all forms and information to be filed with the Department of Revenue (DOR), and have followed all other
requirements in Pub. 3112, IRS e-file Application and Participation and Pub. 4163, Modernized e-File (MeF) Information for Authorized IRS e-file Providers. If I am also the
Paid Preparer, under penalties of perjury, I declare that I have examined the above pass-through entity's return and accompanying schedules and statements, and to the best
of my knowledge and belief, they are true, correct and complete. This Paid Preparer declaration is based on all information of which I have any knowledge.
ERO'S
ERO's Signature
Date
Check if Also
Check if Self-
ERO's SSN or PTIN
Paid Preparer
Employed
Use
Only
Firm's Name (or yours if
EIN
self-employed), address and
ZIP code
Phone No. (
)
Under penalties of perjury, I declare that I have examined the above pass-through entity's return and accompanying schedules and statements, and to the best of my
knowledge and belief, they are true, correct, and complete. This declaration is based on all information of which I have any knowledge.
Preparer's Signature
Date
Check if Also
Preparer's SSN or PTIN
Paid
Check if Self-
Paid Preparer
Employed
Preparer's
Use Only
Firm's Name (or yours if
EIN
self-employed),
address and ZIP code
Phone No. (
)
ELECTRONIC RETURN ORIGINATOR (ERO) RETAIN THIS FORM IN YOUR FILES