Form 83-105-11-1-000 - Corporate Income And Franchise Tax Return

Form 83-105-11-1-000 - Corporate Income And Franchise Tax Return - 2011 Page 2

Mississippi

Form 83-105-11-8-2-000 (Rev. 08/11)

Corporate Income and Franchise Tax Return

2011

831051182000

Page 2

FEIN

__ __ - __ __ __ __ __ __ __

PART l

CORPORATE INFORMATION

1. Is this a publicly traded corporation?

Yes

If Yes, under what symbol? _______________

2. If final return, enter reason and date effective: ______________________________________________

Date _________________________

3. If the corporation has been sold or merged, complete the following: Name, address and FEIN of the new existing corporation:

____________________________________________________________________________________

FEIN _________________________

PART lI

CORPORATE OFFICER INFORMATION

List the owners, officers, directors or partners who have a responsibility in the fiscal management of the organization. Attach schedule if needed.

Ownership

Officer Name and Title

Address

SSN

Percentage

PART lII

CORPORATE AFFILIATION SCHEDULE

List all entities owned by and affiliated with the corporation. See page 2 for additional schedule if needed.

Entity Name

FEIN

Address

Entity Type

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.

Officer Signature and Title

Date

Business Phone

Paid Preparer Signature

Date

Paid Preparer Address

Paid Firm Identification Number

Paid Preparer PTIN

Preparer Phone

Mail Return To

: DEPARTMENT OF REVENUE P.O. BOX 23050 JACKSON, MS 39225-3050