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06Form 84-381-23-3-1-000 (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
05 05
Pass-Through Entity Election Form
06 843812331000 2023 06
07 07
08 08
09 09
10 Tax Year Beginning 99999999 Tax Year Ending 99999999 10
11 11
12 12
13 Partnership / LLC / LLP S Corporation 13
14 FEIN 999999999 X (Federal 1065) X (Federal 1120-S) 14
15 15
16 ENTITY INFORMATION 16
17 Business Name and DBA CHECK ONE 17
18 X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X 18
19 Address X Electing PTE X Removing PTE 19
20 X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X 20
21 City State Zip +4 21
22 X9X9X9X9X9X9X9X9X9X9X9 XX 999999999 Effective date 99999999 22
23 County NAICS Code Total Number of Owners/Partners 23
24 99 999999 9999999999 24
25 RESPONSIBLE PARTY 25
26 Name Title 26
27 X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9 27
28 Address Email 28
29 X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9 29
30 City State Zip +4 Phone 30
31 X9X9X9X9X9X9X9X9X9X9X9 XX 999999999 (999)999-9999 31
32 32
Check box if the election to be taxed at the entity level has been approved by vote satisfying the threshold required for taking official actions as
33 X specified within the entity's governing documents. If the entity's governing documents do not contain any such provisions, then the election 33
34 was accomplished by vote or written consent of the owners, members, partners or shareholders holding greater than fifty percent (50%) of the 34
35 voting control of the entity, and also if the entity has a governing body, by vote or written consent of the governing body of the entity. 35
36 36
37I 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, 37
38this is a true, correct and complete return. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. 38
39 39
40 X9X9X9X9X9X9X9X9X9 99999999 40
41 Officer Signature Title Date 41
42 99999999 X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9X42
43 Paid Preparer Signature Date Paid Preparer Address 43
44 9X9X9X9X9 (999)999-9999 X9X9X9X9X9X9X9X9 XX 999999999 44
45 Paid Preparer PTIN Paid Preparer Phone City State Zip Code 45
46 46
47 X Check box if return may be discussed with preparer 47
48 48
49 49
50 INSTRUCTIONS 50
51 51
52 Complete this form to make an election to pay taxes at the entity level ("Electing PTE") or to revoke a previous election made. The "Electing PTE" 52
status shall be valid for the current taxable year and each taxable year thereafter until the election is revoked.
53 53
54 Elections and revocations must be made by the due date or the extended due date of the Pass-Through Entity Tax Return of the taxable year, or 54
55 by the date such return is filed, whichever is latest for which the entity elects to be taxed as an electing PTE or revoked as an electing PTE. The 55
56 effective date of the election or revocation must be provided on this form. 56
57 Prior to submitting this form, a vote by or written consent of the members of the governing body of the entity, as well as, a vote by or written consent 57
58 of the owners, members, partners or shareholders holding greater than fifty percent (50%) of the voting control of the entity must be obtained in 58
59 order to be taxed as an electing PTE. Acknowledgment of this consent is provided by checking the check box on this form above. 59
60 Mail To: Department of Revenue 60
61 P.O. Box 23191 61
Jackson, MS 39225-3191
62 62
63 63
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