Form 80-107-22-8-1-000 (Rev. 10/22)

                                                                         Mississippi
                                                                                                                                Reset Form
                                      Income / Withholding Tax Schedule
801072281000
                                                                         2022                                                   Print Form

Primary Taxpayer Name (as shown on Forms 80-105, 80-205 and 81-110)

    THIS FORM MUST BE FILED EVEN IF YOU HAVE NO MISSISSIPPI WITHHOLDING

A -  Statement Information                                         B - Income and Withhholding            C - Employer or Payer Information
     Check appropriate box
                             W-2G                                  State State Wages, Tips, Etc.      .00 Employer or payer name
W-2                                1099                            MS

   If 1099-R, Code in Box 7 
                                                                                                          Address
Employer or Payer ID from W-2 or 1099                                    Mississippi Withholding Only .00
                                                                                                          City, State, ZIP
    Taxpayer Name
                                                                   State Income from Other State      .00
    Taxpayer Social Security Number

A -  Statement Information                                         B - Income and Withhholding            C - Employer or Payer Information
     Check appropriate box
                                                                   MS
W-2                          W-2G  1099                            State                              .00 Employer or payer name
                                                                         State Wages, Tips, Etc.
   If 1099-R, Code in Box 7 
                                                                                                          Address
Employer or Payer ID from W-2 or 1099                                    Mississippi Withholding Only .00
                                                                                                          City, State, ZIP
    Taxpayer Name
                                                                   State Income from Other State      .00
    Taxpayer Social Security Number

A -  Statement Information                                         B - Income and Withhholding            C - Employer or Payer Information
     Check appropriate box
                                                                   MS
W-2                          W-2G  1099                            State                              .00 Employer or payer name
                                                                         State Wages, Tips, Etc.
   If 1099-R, Code in Box 7 
                                                                                                          Address
Employer or Payer ID from W-2 or 1099                                    Mississippi Withholding Only .00
                                                                                                          City, State, ZIP
    Taxpayer Name
                                                                   State Income from Other State      .00
    Taxpayer Social Security Number

A -  Statement Information                                         B - Income and Withhholding            C - Employer or Payer Information
     Check appropriate box
                                                                   MS
W-2                          W-2G  1099                            State                              .00 Employer or payer name
                                                                         State Wages, Tips, Etc.
   If 1099-R, Code in Box 7 
                                                                                                          Address
Employer or Payer ID from W-2 or 1099                                    Mississippi Withholding Only .00
                                                                                                          City, State, ZIP
    Taxpayer Name
                                                                   State Income from Other State      .00
    Taxpayer Social Security Number

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