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  06Form 84-115-23-3-1-000 (Rev. 10/23)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
05MS8453-PTE                                                                         Pass-Through Entity Declaration for Electronic Filing                                                                                                                          05
06                                                                                                                                                                                                                                                                  06
07                                                                                                                                           2023                                                                                                                   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
12 X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X                                                                                                                                                                                      12
13 Legal Name and DBA                                                                                                                                                                                                                                               13
14 X9X9X9X9X9X9X9X9X9X9X9X9X9X    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 7 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 am                                                                                       41
  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 other                                                                                   42
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                                                                                                                                                                                                                               9X9X9X9X9                 58
  Use Only
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
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                                                                                          DO NOT Mail this Document to the Mississippi Department of Revenue






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