Form 80-107-22-3-1-000 (Rev. 07/22)
0606 0707 08009 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 79 808 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
0404 Mississippi 0404
0505 0505
Income / Withholding Tax Schedule
0606 801072231000 0606
0707 2022 0707
0808 0808
0909 Primary Taxpayer Name (as shown on Forms 80-105, 80-205 and 81-110) 0909
1010X9X9X9X9X9X9X9X9X9X9X9X9X9X9X9 1010
1111 1111
1212 THIS FORM MUST BE FILED EVEN IF YOU HAVE NO MISSISSIPPI WITHHOLDING 1212
1313 1313
1414 A - Statement Information B - Income and Withhholding C - Employer or Payer Information 1414
1515 Check appropriate box 1515
1616 X W-2 X W-2G X 1099 MS 9999999999 X9X9X9X9X9X9X9X9X9X9X9X9X 1616
1717 State State Wages, Tips, Etc. Employer or payer name 1717
1818 If 1099-R, Code in Box 7 X9 X9X9X9X9X9X9X9X9X9X9X9X9X 1818
1919 Address 1919
999999999 9999999999
2020 Employer or Payer ID from W-2 or 1099 Mississippi Withholding Only 2020
XXXXXXXXXXXXXXXXX XX 99999
2121 City, State, ZIP 2121
XXXXXXXXXXXXXXXXXXX
2222 Taxpayer Name 2222
XX 9999999999
2323 State Income from Other State 2323
999999999
2424 Taxpayer Social Security Number 2424
2525 2525
2626 A - Statement Information B - Income and Withhholding C - Employer or Payer Information 2626
2727 Check appropriate box 2727
2828 X W-2 X W-2G X 1099 MS 9999999999 X9X9X9X9X9X9X9X9X9X9X9X9X 2828
2929 State State Wages, Tips, Etc. Employer or payer name 2929
3030 If 1099-R, Code in Box 7 X9 X9X9X9X9X9X9X9X9X9X9X9X9X 3030
3131 Address 3131
999999999 9999999999
3232 Employer or Payer ID from W-2 or 1099 Mississippi Withholding Only 3232
XXXXXXXXXXXXXXXXX XX 99999
3333 City, State, ZIP 3333
XXXXXXXXXXXXXXXXXXX
3434 Taxpayer Name 3434
XX 9999999999
3535 State Income from Other State 3535
999999999
3636 Taxpayer Social Security Number 3636
3737 3737
3838 A - Statement Information B - Income and Withhholding C - Employer or Payer Information 3838
3939 Check appropriate box 3939
4040 X W-2 X W-2G X 1099 MS 9999999999 X9X9X9X9X9X9X9X9X9X9X9X9X 4040
4141 State State Wages, Tips, Etc. Employer or payer name 4141
4242 If 1099-R, Code in Box 7 X9 X9X9X9X9X9X9X9X9X9X9X9X9X 4242
4343 Address 4343
999999999 9999999999
4444 Employer or Payer ID from W-2 or 1099 Mississippi Withholding Only 4444
XXXXXXXXXXXXXXXXX XX 99999
4545 City, State, ZIP 4545
XXXXXXXXXXXXXXXXXXX
4646 Taxpayer Name 4646
XX 9999999999
4747 State Income from Other State 4747
999999999
4848 Taxpayer Social Security Number 4848
4949 4949
5050 A - Statement Information B - Income and Withhholding C - Employer or Payer Information 5050
5151 Check appropriate box 5151
5252 X W-2 X W-2G X 1099 MS 9999999999 X9X9X9X9X9X9X9X9X9X9X9X9X 5252
5353 State State Wages, Tips, Etc. Employer or payer name 5353
5454 If 1099-R, Code in Box 7 X9 X9X9X9X9X9X9X9X9X9X9X9X9X 5454
5555 Address 5555
999999999 9999999999
5656 Employer or Payer ID from W-2 or 1099 Mississippi Withholding Only 5656
XXXXXXXXXXXXXXXXX XX 99999
5757 City, State, ZIP 5757
XXXXXXXXXXXXXXXXXXX
5858 Taxpayer Name 5858
XX 9999999999
5959 State Income from Other State 5959
999999999
6060 Taxpayer Social Security Number 6060
6161 6161
6262 6262
6363 Duplex and Photocopies NOT Acceptable 6363
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