Form 84-380-22-3-1-000 (Rev 04/22)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                                                                                                                                                                                                                                                                  05
06                                       Non-Resident Income Tax Agreement                                                                                                                                                                                          06
07                                                       2022                                                                                                                                                                                                       07
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10 Tax Year Beginning 99999999                                                  Tax Year Ending       99999999                                                                                                                                                      10
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13 FEIN 999999999                                                               SSN                   999999999                                                                                                                                                     13
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16 Business Name                                         Name of Taxpayer                                                                                                                                                                                           16
17X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X                    X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X                                                                                                                                                                    17
18 Address                                               Address                                                                                                                                                                                                    18
19X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X                    X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X                                                                                                                                                                    19
20                                                                                                                                                                                                                                                                  20
21X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X                    X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X                                                                                                                                                                    21
22 City                                 State Zip +4     City                   State                 Zip +4                                                                                                                                                        22
23X9X9X9X9X9X9X9X9X9                    XX    999999999  X9X9X9X9X9X9X9X9X9     XX                    999999999                                                                                                                                                     23
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26                                                   AGREEMENT                                                                                                                                                                                                      26
27                                                                                                                                                                                                                                                                  27
28 Pursuant to Miss. Code Ann. Section 27-8-19(4), I hereby covenant and agree:                                                                                                                                                                                     28
29                                                                                                                                                                                                                                                                  29
30(1)   To timely file a Mississippi Non-Resident Income Tax Return (Form 80-205) and make timely payment of all taxes                                                                                                                                              30
31       imposed by Mississippi upon my pro rata share of income (loss) in the above named S corporation for the year above31
32       and all subsequent taxable years for which I am a shareholder.                                                                                                                                                                                             32
33                                                                                                                                                                                                                                                                  33
34(2)   To be subject to personal jurisdiction in this state for purposes of the collection of income taxes, together with                                                                                                                                          34
35       related interest and penalties, imposed on the shareholder by this state with respect to the income of the S                                                                                                                                               35
36       corporation.                                                                                                                                                                                                                                               36
37                                                                                                                                                                                                                                                                  37
38I further certify that I am or have been a shareholder of said corporation during its taxable year.                                                                                                                                                               38
39                                                                                                                                                                                                                                                                  39
40This agreement shall be binding upon my heirs, representatives, assigns, successors, executors and administrators.                                                                                                                                                40
41                                                                                                                                                                                                                                                                  41
42                                                                                                                                                                                                                                                                  42
43Signature of Non-Resident Shareholder                                  Date                                                                                                                                                                                       43
44                                                                                                                                                                                                                                                                  44
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47                                                                                                                                                                                                                                                                  47
48•  Do not file this agreement with the S Corporation Tax Return.                                                                                                                                                                                                  48
49                                                                                                                                                                                                                                                                  49
50 •  Retain this agreement in your permanent tax files.                                                                                                                                                                                                            50
51                                                                                                                                                                                                                                                                  51
52•  This form may be reproduced.                                                                                                                                                                                                                                   52
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