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Mississippi

Form 84-115-12-8-1-000 Rev. (05/12)

Pass - Through Entity

Declaration for Electronic Filing

2012

MS8453-PTE

For Calendar Year 2011, or Tax Year Beginning

, Ending

, 20

IRS DECLARATION CONTROL NUMBER

00-

-0

Duplex or Photocopies NOT Acceptable

Name

FEIN

Mailing Address (P O Box or Street Including Rural Route)

City

State

Zip +4

County Code

(See Instructions)

DO NOT MAIL THIS DOCUMENT TO THE DOR

ELECTRONIC RETURN ORIGINATOR (ERO) RETAIN THIS FORM IN YOUR FILES

TAX RETURN INFORMATION (Round to the Nearest Dollar)

PART I:

Mississippi Taxable Income (Form 84-105, Line 5)

__ __ __ __ __ __ __ __ __ __

............... .......................

Total Income Tax (Form 84-105, Line 6)

__ __ __ __ __ __ __ __ __ __

. .......................................................

Total Payments & Credits (Form 84-105, Line 7 and Line 12)

__ __ __ __ __ __ __ __ __ __

Amount You Owe (Form 84-105, Line 18)

__ __ __ __ __ __ __ __ __ __

.. ............................................. ..

Overpayment (Form 84-105, Line 19)

__ __ __ __ __ __ __ __ __ __

..................................................

Refund (Form 84-105, Line 21)

__ __ __ __ __ __ __ __ __ __

.............. ...................................... .....

Amount of Payment Remitted Electronically

__ __ __ __ __ __ __ __ __ __

. ....................................... . ..

* If the corporation is filing a balance due return and the Department of Revenue does not receive full and timely payment of its tax liability, the

corporation will be liable for the tax liability and all applicable interest and penalties.

DECLARATION OF OFFICER (See Instructions)

PART II:

Under the penalties of perjury, I declare that I am an officer of the above corporation and that the information I have given my electronic return

originator (ERO), transmitter, and/or intermediate service provider (ISP) and the amounts in Part I above agree with the amounts on the corresponding

lines of the corporation's Mississippi Corporate Income & Franchise Tax Return. To the best of my knowledge and belief, the corporation's return is

true, correct and complete. I consent to my ERO, transmitter, and/or ISP sending the corporation's return, this declaration, and accompanying

schedules and statements to the Department of Revenue (DOR). I also consent to the DOR my ERO, transmitter, and/or ISP an acknowledgement of

receipt of transmission and an indication of whether or not the corporation's return is accepted, and, if rejected, the reason(s) for the rejection. This

declaration is to be maintained by the ERO and provided to DOR on request.

Sign

Signature of Officer

Title

Here

Date

lll:

DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER (See Instructions)

PART

I declare that I have reviewed the above corporation's return and that the entries on Form MS8453-C are complete and correct to the best of my

knowledge. If I am only a collector, I am not responsible for reviewing the return and only declare that this form accurately reflects the data on the

return. The corporate officer will have signed this form before I submit the return. I will give the officer a copy of all forms and information to be filed

with the Department of Revenue (DOR), and have followed all other requirements in Pub. 3112, IRS e-file Application and Participation and Pub. 4163,

Modernized e-File (MeF) Information for Authorized IRS e-file Providers. If I am also the Paid Preparer, under penalties of perjury, I declare that I have

examined the above corporation's return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true,

correct and complete. This Paid Preparer declaration is based on all information of which I have any knowledge.

Check if Also

Check if Self-

Date

ERO's SSN or PTIN

Paid Preparer

Employed

ERO's Signature

ERO'S

Firm's Name (or your's if Self-

Use