Form 84-380-12-8-1-000 - Mississippi Non-Resident Income Tax Agreement

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Mississippi
Form 84-380-12-8-1-000 (Rev 05/12)
MS
Non-Resident Income Tax Agreement
Tax Year Beginning
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Tax Year Ending
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y
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FEIN
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SSN
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Business Name
Name of Taxpayer
Address
Address
City
State
Zip +4
City
State
Zip +4
AGREEMENT
Pursuant to Miss. Code Ann. Section 27-8-19(4), I hereby covenant and agree:
(1) To timely file a Mississippi Non-Resident Income Tax Return (Form 80-205) and make timely payment of all taxes
imposed by Mississippi upon my pro rata share of income/loss in the above named S Corporation for the year above
and all subsequent taxable years for which I am a shareholder.
(2) To be subject to personal jurisdiction in this state for purposes of the collection of income taxes, together with
related interest and penalties, imposted on the shareholder by this state with respect to the income of the S
corporation.
I further certify that I am or have been a shareholder of said corporation during its taxable year.
This agreement shall be binding upon my heirs, representatives, assigns, successors, executors and administrators.
Signature of Non-Resident Shareholder
Date
Do not file this agreement with the S-Corporation Tax Return.
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Retain this agreement in your permanent tax files.
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This form may be reproduced.
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