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Form 80-115-22-8-1-000 (Rev. 10/22)
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Mississippi
MS8453-IIT Individual Income Tax Declaration
Submission Number
For Electronic Filing
2022
Taxpayer First Name Initial Last Name
YOU MUST ENTER SSN
Spouse First Name Initial Last Name
Taxpayer SSN
Mailing Address (Number and Street, Including Rural Route)
Spouse SSN
City State Zip County Code
PART I: TAX RETURN INFORMATION (ROUND TO THE NEAREST DOLLAR)
1 Mississippi taxable income (Form 80-105, line 16; 80-205, line 19) 1 .00
2 Total Mississippi tax (Form 80-105, line 24; 80-205, line 26) 2 .00
3 Mississippi tax payments (Form 80-105, line 28; 80-205, line 30) 3 .00
4 Refund (Form 80-105, line 34; 80-205, line 35) 4 .00
5 Amount you owe (Form 80-105, line 37; 80-205, line 38) 5 .00
PART II: DIRECT DEPOSIT/DIRECT DEBIT
1 Routing number 3 Type of account: Checking Savings
2 Account number
4 Routing number 6 Type of account: Checking Savings
5 Account number
My request for direct deposit/direct debit of my refund/payment includes my authorization for the Mississippi Department of Revenue to furnish my financial institution with my
routing number, account number, account type, and social security number to insure my refund/payment is properly processed.
PART III: DECLARATION OF TAXPAYER
Under penalties of perjury, I declare that I have compared the information contained on my income tax return with the information I have provided to my electronic return
originator and that the amounts described in Part I above agree with the amounts shown on the corresponding lines of my Mississippi income tax return. To the best of my
knowledge and belief, my return is true, correct and complete. This declaration is to be maintained by the electronic return originator and provided to Mississippi Department of
Revenue on request.
Taxpayer Signature Date Spouse Signature Date
PART IV: DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER
Under penalties of perjury, I declare that I have reviewed the above taxpayer's return and that the entries on this form are complete and correctly represented to the best of my
knowledge. I have obtained the taxpayer's signature and will maintain this return for the Mississippi Department of Revenue as part of my permanent records. Upon written
request, I will furnish this return to the Mississippi Department of Revenue. I have provided the taxpayer with a copy of all forms and information to be filed electronically with
the Mississippi Department of Revenue and have followed all other requirements described in the Mississippi Handbook for Electronic Filers and any additional requirements
specified by the Mississippi Department of Revenue. If I am the paid preparer, under penalties of perjury, I declare that I have examined this return and accompanying
schedules and statements and to the best of my knowledge and belief, they are true, correct and complete. Declaration of preparer is based on all information of which
preparer has any knowledge.
ERO ERO Signature Date Check if Also Check if Self- ERO SSN or PTIN
Use Paid Preparer Employed
Only EIN
Firm Name (or yours if self-
employed), address and ZIP code Phone No.
Under penalties of perjury, I declare that I have examined the above taxpayer's return and accompanying schedules and statements, and to the best of my knowledge and
belief, they are true, correct, and complete. This declaration is based on all information of which I have any knowledge.
Paid Preparer Signature Date Check if Also Check if Self- Preparer SSN or PTIN
Paid Preparer Employed
Preparer
Use Only EIN
Firm Name (or yours if self-
employed), address and ZIP code Phone No.
DO NOT Mail this Document to the Mississippi Department of Revenue
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