Form 84-105-14-8-1-000 - Mississippi Pass-Through Entity Tax Return - 2014 Page 3

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Form 84-105-14-8-3-000 (Rev. 05/14)

Mississippi

Pass-Through Entity Schedule

841051483000

Page 3

2014

FEIN

PART lII

Q-SUB/DISREGARDED ENTITY SCHEDULE

List all qualified subchapter S subsidiaries (Q-Sub) and/or disregarded entities. Attach additional schedule(s), Form 84-105, page 4, if needed.

MISSISSIPPI OPERATIONS

ENTITY NAME

FEIN

ADDRESS

(Y/N)

PART IV

ENTITY OFFICER INFORMATION

List the owners, officers, directors, or partners who have a responsibility in the fiscal management of the organization.

OWNERSHIP

OFFICER NAME AND TITLE

SSN

ADDRESS

PERCENTAGE

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.

Officer Signature and Title

Date

Business Phone

Paid Preparer Signature

Date

Paid Preparer Address

Paid Preparer PTIN

Paid Preparer Phone

City

State

Zip Code

Mail Return To: Department of Revenue P.O. BOX 23050 Jackson, MS 39225-3050