Form 80-115-06-3-1-000 - Individual Income Tax Declaration For Electronic Filing - State Of Mississippi - 2006

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Form 80-115-06-3-1-000 Rev. (5/06)
Mississippi
Electronic Return
Individual Income Tax Declaration
Originator (ERO).
For Electronic Filing
2006
MS8453
IRS DECLARATION CONTROL NUMBER
Duplex or Photocopies NOT Acceptable
00-
-7
Taxpayer Last Name
Taxpayer First Name
Middle Initial
Taxpayer SSN
Spouse First Name
Spouse Middle Initial
Spouse Last Name
Spouse SSN
Mailing Address (Number & Street, Including Rural Route)
Residence
County Code
State
ZIP
City
PART I:
PART I:
TAX RETURN INFORMATION (Round to the Nearest Dollar)
1.
Mississippi Taxable Income
1.
2.
2.
Total Misissippi Tax
Total Misissippi Tax
2.
2.
3.
Mississippi Tax Payments & Credits
3.
4.
Refund
4.
Amount You Owe
5.
5.
PART II:
DIRECT DEPOSIT
1.
1.
Routing Number
2.
Account Number
2.
3. Type of Account
Checking
Savings
My request for direct deposit of my refund includes my authorization for the Mississippi State Tax Commission to furnish my financial institution with
my routing number, account number, account type, and social security number to insure my refund is properly deposited.
PART III:
DECLARATION OF TAXPAYER
Under penalties of perjury, I declare that I have compared the information contained on my income tax return with the information I have provided to
my electronic return originator and that the amounts described in Part I above agree with the amounts shown on the corresponding lines of my
Mississippi income tax return. To the best of my knowledge and belief, my return is true, correct and complete. This declaration is to be maintained
by the electronic return originator and provided to Mississippi State Tax Commission on request.
Signature of Taxpayer
Date
Signature of Spouse
Date
PART IV:
DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER
Under penalties of perjury, I declare that I have reviewed the above taxpayer's return and that the entries on this form are complete and correctly
represented to the best of my knowledge. I have obtained the taxpayer's signature and will maintain this return for the Mississippi State Tax
Commission as part of my permanent records. Upon written request, I will furnish this return to the Mississippi State Tax Commission. I have
provided the taxpayer with a copy of all forms and information to be filed electronically with the Mississippi State Tax Commission and have followed
all other requirements described in the Mississippi Handbook for Electronic Filers and any additional requirements specified by the Mississippi State
Tax Commission. If I am the paid preparer, under penalties of perjury, I declare that I have examined this return and accompanying schedules and
statements and to the best of my knowledge and belief, they are true, correct and complete. Declaration of preparer is based on all information of
which preparer has any knowledge.
ERO USE ONLY
Social Security Number or PTIN
Check If:
ERO Signature
Date
Paid Preparer
Employer Identification Number or PTIN
Firm Name & Address
(Preparer Address if Self-Employed)
Self-Employed
Paid Preparer Use Only
Social Security Number or PTIN
Check If:
Paid Preparer Signature
Date
Self-Employed
Firm Name & Address
(Preparer Address if Self-Employed)
Employer Identification Number or PTIN
Do NOT Mail this Document to the Mississippi State Tax Commission

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