Form 80-107-12-8-1-000 - Income / Withholding Tax Schedule - 2012

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Form 80-107-12-8-1-000 (Rev. 05/12)
MS
Mississippi
Income / Withholding Tax Schedule
Page 1
801071281000
2012
Primary Taxpayer's Name (As shown on Forms 80-105, 80-110, 80-205 and 81-110)
1
A - Employer or Payer Information
B - Taxpayer Wage Information
C - MS Tax Withheld
MS WITHHOLDING
__ __ - __ __ __ __ __ __ __
__, __ __ __, __ __ __.
00
Employer or payer ID from W-2, 1099, K-1
Name
Check appropriate box.
__ __ __ - __ __ - __ __ __ __
W-2
1099
K-1
Employer or payer name
Social Security Number
MS
__, __ __ __, __ __ __.
00
__ __
__ __
If 1099-R, Code in Box 7
Mississippi Taxable Income
Address
State
__, __ __ __, __ __ __.
00
Mississippi Withholding Only
__ __
City, State, ZIP
State
Income from Other State
1
A - Employer or Payer Information
B - Taxpayer Wage Information
C - MS Tax Withheld
MS WITHHOLDING
__ __ - __ __ __ __ __ __ __
__, __ __ __, __ __ __.
00
Employer or payer ID from W-2, 1099, K-1
Name
Check appropriate box.
__ __ __ - __ __ - __ __ __ __
1099
K-1
W-2
Employer or payer name
Social Security Number
__ __
__, __ __ __, __ __ __.
00
__ __
If 1099-R, Code in Box 7
State
Mississippi Taxable Income
Address
__, __ __ __, __ __ __.
00
Mississippi Withholding Only
__ __
City, State, ZIP
State
Income from Other State
1
A - Employer or Payer Information
B - Taxpayer Wage Information
C - MS Tax Withheld
MS WITHHOLDING
__ __ - __ __ __ __ __ __ __
__, __ __ __, __ __ __.
00
Employer or payer ID from W-2, 1099, K-1
Name
Check appropriate box.
__ __ __ - __ __ - __ __ __ __
1099
K-1
W-2
Employer or payer name
Social Security Number
__ __
__, __ __ __, __ __ __.
00
__ __
If 1099-R, Code in Box 7
State
Mississippi Taxable Income
Address
__, __ __ __, __ __ __.
00
Mississippi Withholding Only
__ __
City, State, ZIP
State
Income from Other State
1
A - Employer or Payer Information
B - Taxpayer Wage Information
C - MS Tax Withheld
MS WITHHOLDING
__ __ - __ __ __ __ __ __ __
__, __ __ __, __ __ __.
00
Employer or payer ID from W-2, 1099, K-1
Name
Check appropriate box.
__ __ __ - __ __ - __ __ __ __
1099
W-2
K-1
Employer or payer name
Social Security Number
__ __
__, __ __ __, __ __ __.
00
__ __
If 1099-R, Code in Box 7
State
Address
Mississippi Taxable Income
__ __
__, __ __ __, __ __ __.
00
Mississippi Withholding Only
City, State, ZIP
State
Income from Other State
THIS FORM MUST BE FILED EVEN IF YOU HAVE NO MISSISSIPPI WITHHOLDING
Duplex and Photocopies NOT Acceptable

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