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06Form07 0884-115-22-3-1-00009 10 11 12 13 14 15(Rev.16 1706/22)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
05MS8453-PTE Pass-Through Entity Declaration for Electronic Filing 05
06 06
07 2022 07
08Tax Year Beginning 99999999 Tax Year Ending 99999999 08
09 DO NOT MAIL THIS DOCUMENT 09
10 FEIN 999999999 TO THE DEPARTMENT OF REVENUE 10
11 11
12X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X 12
13 Legal Name and DBA 13
14X9X9X9X9X9X9X9X9X9X9X9X9X9X X9X9X9X9X9X9X9X9X XX 999999999 99 14
15 Address City State Zip +4 County Code 15
16 16
17 PART I: TAX RETURN INFORMATION (ROUND TO THE NEAREST DOLLAR) 17
18 18
191 Mississippi taxable income (Form 84-105, line 5) 1 9999999999 19
202 Total income tax (Form 84-105, line 6) 2 9999999999 20
213 Total credits and payments (Form 84-105, line 8 and line 13) 3 9999999999 21
224 Amount you owe (Form 84-105, line 19) 4 9999999999 22
235 Overpayment (Form 84-105, line 20) 5 9999999999 23
246 Refund (Form 84-105, line 22) 6 9999999999 24
257 Amount of payment remitted electronically 7 9999999999 25
26 26
27 * If the pass-through entity is filing a balance due return and the Department of Revenue does not receive full and timely payment of its tax liability, 27
28 the pass-through entity will be liable for the tax liability and all applicable interest and penalties. 28
29 29
30 PART II: DECLARATION OF OFFICER 30
31 31
32Under the penalties of perjury, I declare that I am an officer of the above pass-through entity and that the information I have given my electronic return originator (ERO),32
transmitter, and/or intermediate service provider (ISP) and the amounts in Part I above agree with the amounts on the corresponding lines of the pass-through entity's
33Mississippi Pass-Through Entity Tax Return. To the best of my knowledge and belief, the pass-through entity's return is true, correct and complete. I consent to my ERO,33
34transmitter, and/or ISP sending the pass-through entity's return, this declaration, and accompanying schedules and statements to the Department of Revenue (DOR). I also 34
consent to the DOR my ERO, transmitter, and/or ISP an acknowledgement of receipt of transmission and an indication of whether or not the pass-through entity's return is
35accepted, and, if rejected, the reason(s) for the rejection. This declaration is to be maintained by the ERO and provided to DOR on request. 35
36 Sign 36
37 Here Signature of Officer Date Title 37
38 38
39 PART lll: DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER 39
40 40
41I declare that I have reviewed the above pass-through entity's return and that the entries on Form MS8453-PTE are complete and correct to the best of my knowledge. If I am41
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
42this 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 other42
43requirements 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 43
Paid Preparer, under penalties of perjury, I declare that I have examined the above pass-through entity's return and accompanying schedules and statements, and to the best
44of 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. 44
45 45
46 ERO ERO Signature Date Check if Also Check if Self- ERO SSN or PTIN 46
Use Paid Preparer X Employed X
9X9X9X9X9
47 Only Firm Name (or yours if EIN 47
48 48
self-employed), address
49 and ZIP code X9X9X9X9X9X9X9 X9X9X9X9X9X9X9 XX 99999 999999999 49
50 Phone No. 50
51 (999)999-9999 51
52 52
53 53
54Under penalties of perjury, I declare that I have examined the above pass-through entity's return and accompanying schedules and statements, and to the best of my 54
knowledge and belief, they are true, correct, and complete. This declaration is based on all information of which I have any knowledge.
55 55
56 56
57 Paid Preparer Signature Date Check if Also Check if Self- Preparer SSN or PTIN 57
Paid Preparer X Employed X
58 Preparer 58
Use Only 9X9X9X9X9
59 Firm Name (or yours if EIN 59
self-employed), address
60 and ZIP code X9X9X9X9X9X9X9 X9X9X9X9X9X9X9 XX 99999 999999999 60
61 Phone No. 61
62 (999)999-9999 62
63 63
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
DO NOT Mail this Document to the Mississippi Department of Revenue