Form 83-180-12-8-1-000 - Application For Automatic Six-Month Extension - 2012
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1
2Mississippi
Form 83-180-12-8-1-000 (Rev. 05/12)
MS
Application for Automatic Six-Month Extension
831801281000
Tax Year Beginning
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Tax Year Ending
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m
m
d
d
y
y
y
y
m
m
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FEIN
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MS Secretary of State ID
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Business Name and DBA
Check All That Apply
Address
C Corporation
Initial Return
S Corporation
Final Return
City
State
Zip+4
_
Partnership / LLC / LLP
Composite Return
1. Extension Payment Amount
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Enter the total amount of payment remitted by reporting entity for all members of affiliated group listed below.
Affiliated Member Name
Amount of Payment
Identification Number
FEIN
SSN
Reporting Entity
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2.
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Affiliated Members
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3.
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4.
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6.
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8.
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10.
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11.
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13.
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14.
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15.
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16. Total of Amounts Entered on Lines 2 Through 15
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17. Total Amounts from All Additional Pages (Form(s) 83-180)
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18. Total Extension Payment
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(Add Lines 16 and 17. Should equal total amount of payment entered on Line 1.)
I 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, this is a true, correct and complete return.
Title
Date
Officer / Agent Signature
Mail To: Department of Revenue
P.O. Box 23050
Jackson, MS 39225-3050
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