Form 80-115-12-8-1-000 - Mississippi Individual Income Tax Declaration For Electronic Filing - 2012

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Form 80-115-12-8-1-000 Rev. (7/12)

Mississippi

Electronic Return

Individual Income Tax Declaration

Originator (ERO)

For Electronic Filing

IRS DECLARATION CONTROL NUMBER

2012

MS8453

00-

-3

Middle Initial

YOU MUST ENTER SSN

Taxpayer Last Name

First Name

__ __ __ - __ __ - __ __ __ __

Spouse Last Name

Spouse First Name

Middle Initial

SSN

Spouse

__ __ __ - __ __ - __ __ __ __

Mailing Address (Number & Street, Including Rural Route)

SSN

State

Zip

City

__ __

Residence County Code - See Instructions

PART I: PART I: TAX RETURN INFORMATION

(Round to the Nearest Dollar)

1. Mississippi Taxable Income

___

___ ___ ___

2. Total Mississippi Tax

___

___ ___ ___

3. Mississippi Tax Payments & Credits

___

___ ___ ___

4. Refund

___

___ ___ ___

5. Amount You Owe

___

___ ___ ___

PART II: DIRECT DEPOSIT

1. Routing Number

___

___ ___ ___

2. Account Number

___

___ ___ ___

3. Type of Account

Checking

Savings

My request for direct deposit of my refund includes my authorization for the Mississippi Department of Revenue to furnish my financial institution with my

routing number, account number, account type, and social security number to insure my refund is properly deposited.

PART III:

DECLARATION OF TAXPAYER

Under penalties of perjury, I declare that I have compared the information contained on my income tax return with the information I have provided to my

electronic return originator and that the amounts described in Part I above agree with the amounts shown on the corresponding lines of my Mississippi

income tax return. To the best of my knowledge and belief, my return is true, correct and complete. This declaration is to be maintained by the electronic

return originator and provided to Mississippi Department of Revenue on request.

Signature of Taxpayer

Date

Signature of Spouse

Date

PART IV:

DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER

Under penalties of perjury, I declare that I have reviewed the above taxpayer's return and that the entries on this form are complete and correctly represented to

the best of my knowledge. I have obtained the taxpayer's signature and will maintain this return for the Mississippi Department of Revenue as part of my

permanent records. Upon written request, I will furnish this return to the Mississippi Department of Revenue. I have provided the taxpayer with a copy of all forms

and information to be filed electronically with the Mississippi Department of Revenue and have followed all other requirements described in the Mississippi

Handbook for Electronic Filers and any additional requirements specified by the Mississippi Department of Revenue. If I am the paid preparer, under penalties of

perjury, I declare that I have examined this return and accompanying schedules and statements and to the best of my knowledge and belief, they are true, correct

and complete. Declaration of preparer is based on all information of which preparer has any knowledge.

ERO USE ONLY

Social Security Number or PTIN

Check If:

ERO Signature

Date

Paid Preparer

Employer Identification Number or PTIN

Firm Name & Address

(Preparer Address if Self-Employed)

Self-Employed

Paid Preparer Use Only