Form 83-105-12-8-1-000 - Mississippi Corporate Income And Franchise Tax Return - 2012 Page 2

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Mississippi

Form 83-105-12-8-2-000 (Rev. 05/12)

Corporate Income and Franchise Tax Return

2012

Page 2

831051282000

FEIN

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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 _________________________

4. If amended return, check reason.

Mississippi Correction

Federal Correction

Other

Amended Federal 1120,

Attach statement of explanation, if needed.

Federal Audit (RAR)

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

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

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 3 for additional schedule if needed.

Entity Name

FEIN

Entity Type

Address

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