Form 84-380-23-3-1-000 (Rev 10/23)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
04                                                   Mississippi                                                                                                                                                                                                    04
05                                                                                                                                                                                                                                                                  05
06                                       Non-Resident Income Tax Agreement                                                                                                                                                                                          06
07                                                       2023                                                                                                                                                                                                       07
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10 Tax Year Beginning 99999999                                                  Tax Year Ending       99999999                                                                                                                                                      10
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12                                                                                                                                                                                                                                                                  12
13 FEIN 999999999                                                               SSN                   999999999                                                                                                                                                     13
14                                                                                                                                                                                                                                                                  14
15                                                                                                                                                                                                                                                                  15
16 Business Name                                        Name of Taxpayer                                                                                                                                                                                            16
17 X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X                  X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X17
18 Address                                              Address                                                                                                                                                                                                     18
19 X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X                  X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X19
20                                                                                                                                                                                                                                                                  20
21 X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X                  X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X21
22 City                                 State Zip +4    City                    State                 Zip +4                                                                                                                                                        22
23 X9X9X9X9X9X9X9X9X9                   XX    999999999 X9X9X9X9X9X9X9X9X9      XX                    999999999                                                                                                                                                     23
24                                                                                                                                                                                                                                                                  24
25                                                                                                                                                                                                                                                                  25
26                                                   AGREEMENT                                                                                                                                                                                                      26
27                                                                                                                                                                                                                                                                  27
28 Pursuant to Miss. Code Ann. Section 27-8-19(4), I hereby covenant and agree:                                                                                                                                                                                     28
29                                                                                                                                                                                                                                                                  29
30(1) To timely file a Mississippi Non-Resident Income Tax Return (Form 80-205) and make timely payment of all taxes                                                                                                                                                30
31      imposed by Mississippi upon my pro rata share of income (loss) in the above named S corporation for the year above                                                                                                                                          31
32      and all subsequent taxable years for which I am a shareholder.                                                                                                                                                                                              32
33                                                                                                                                                                                                                                                                  33
34(2) To be subject to personal jurisdiction in this state for purposes of the collection of income taxes, together with                                                                                                                                            34
35      related interest and penalties, imposed on the shareholder by this state with respect to the income of the S                                                                                                                                                35
36      corporation.                                                                                                                                                                                                                                                36
37                                                                                                                                                                                                                                                                  37
38I further certify that I am or have been a shareholder of said corporation during its taxable year.                                                                                                                                                               38
39                                                                                                                                                                                                                                                                  39
40This agreement shall be binding upon my heirs, representatives, assigns, successors, executors and administrators.                                                                                                                                                40
41                                                                                                                                                                                                                                                                  41
42                                                                                                                                                                                                                                                                  42
43Signature of Non-Resident Shareholder                                Date                                                                                                                                                                                         43
44                                                                                                                                                                                                                                                                  44
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47                                                                                                                                                                                                                                                                  47
48•  Do not file this agreement with the S Corporation Tax Return.                                                                                                                                                                                                  48
49                                                                                                                                                                                                                                                                  49
50 • Retain this agreement in your permanent tax files.                                                                                                                                                                                                             50
51                                                                                                                                                                                                                                                                  51
52•  This form may be reproduced.                                                                                                                                                                                                                                   52
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