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Form 83-180-22-3-1-000 (Rev. 08/22)
06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80
04 Mississippi 04
05 Application for Automatic Extension 05
06 831802231000 2022 06
07 07
08 Tax Year Beginning 99999999 Tax Year Ending 99999999 08
09 09
10FEIN 999999999 Mississippi Secretary of State ID 9999999999 10
11 11
Legal Name and DBA
12 CHECK ALL THAT APPLY 12
13X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X 13
14 Address Initial Return 14
X
15X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X X C Corporation 15
16 X Final Return 16
17X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X X S Corporation 17
18City State Zip+4 Composite Return 18
X
19X9X9X9X9X9X9X9X9X9X9X9X9X XX 999999999 X Partnership / LLC / LLP 19
20 X Electing Pass-Through Entity 20
21 21
1
22 Extension payment amount 22
Enter the total amount of payment remitted by the reporting entity for all members of affiliated group listed below. 9999999999
23 23
24 NAME FEIN SSN IDENTIFICATION NUMBER AMOUNT OF PAYMENT 24
25 25
262 X9X9X9X9X9X9X9X9X9X9 X X 999999999 2 9999999999 26
27 27
283 X9X9X9X9X9X9X9X9X9X9 X X 999999999 3 9999999999 28
29 29
304 X9X9X9X9X9X9X9X9X9X9 X X 999999999 4 9999999999 30
31 31
325 X9X9X9X9X9X9X9X9X9X9 X X 999999999 5 9999999999 32
33 33
346 X9X9X9X9X9X9X9X9X9X9 X X 999999999 6 9999999999 34
35 35
367 X9X9X9X9X9X9X9X9X9X9 X X 999999999 7 9999999999 36
37 37
388 X9X9X9X9X9X9X9X9X9X9 X X 999999999 8 9999999999 38
39 39
409 X9X9X9X9X9X9X9X9X9X9 X X 999999999 9 9999999999 40
41 41
4210 X9X9X9X9X9X9X9X9X9X9 X X 999999999 10 9999999999 42
43 43
4411 X9X9X9X9X9X9X9X9X9X9 X X 999999999 11 9999999999 44
45 45
4612 X9X9X9X9X9X9X9X9X9X9 X X 999999999 12 9999999999 46
47 47
4813 X9X9X9X9X9X9X9X9X9X9 X X 999999999 13 9999999999 48
49 49
5014 X9X9X9X9X9X9X9X9X9X9 X X 999999999 14 9999999999 50
51 51
5215 Total of amounts entered on line 2 through line 14 15 999999999 52
53 53
5416 Total amounts from all supplemental pages (Form(s) 83-180) 16 999999999 54
55 55
5617 Total extension payment (add line 15 and line 16; total should equal payment amount on line 1) 17 9999999999 56
57 57
58 58
59I declare, under penalties of perjury, that I have examined this return and accompanying schedules and statements, and to the best of my 59
60knowledge and belief, this is a true, correct and complete return. 60
61 61
62 Officer / Agent Signature Title Date 62
63 63
06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26Mail27 28 29To:30 31Department32 33 34 35 36 37of38 39Revenue40 41 42 43 44P.O.45 46Box47 482319149 50 51 52Jackson,53 54 55 56 57MS58 5939225-319160 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80
