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Form 83-180-22-8-1-000 (Rev. 08/22) Print Form
Mississippi
Application for Automatic Extension
831802281000 2022
Tax Year Beginning Tax Year Ending
mm dd yyyy mm dd yyyy
FEIN Mississippi Secretary of State ID
Legal Name and DBA
CHECK ALL THAT APPLY
Address Initial Return
C Corporation
Final Return
S Corporation
City State Zip+4 Composite Return
Partnership / LLC / LLP
Electing Pass-Through Entity
1 Extension payment amount
Enter the total amount of payment remitted by the reporting entity for all members of affiliated group listed below. .00
NAME FEIN SSN IDENTIFICATION NUMBER AMOUNT OF PAYMENT
2 2 .00
3 3 .00
4 4 .00
5 5 .00
6 6 .00
7 7 .00
8 8 .00
9 9 .00
10 10 .00
11 11 .00
12 12 .00
13 13 .00
14 14 .00
15 Total of amounts entered on line 2 through line 14 15 .00
16 Total amounts from all supplemental pages (Form(s) 83-180) 16 .00
17 Total extension payment (add line 15 and line 16; total should equal payment amount on line 1) 17 .00
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.
Officer / Agent Signature Title Date
Mail To: Department of Revenue P.O. Box 23191 Jackson, MS 39225-3191
