2025 Form 84-380 Non-Residence Income Tax Agreement

Form 84-380-25-8-1-000 (Rev 10/25)
Business Name Name of Taxpayer
Address
City State Zip +4 City State Zip +4
Pursuant to Miss. Code Ann. Section 27-8-19(4), I hereby covenant and agree:
To timely file a Mississippi Non-Resident Income Tax Return (Form 80-205) and make timely payment of all taxes imposed by Mississippi upon my pro rata share of income (loss) in the above named S corporation for the year above and all subseq uent taxable years for which I am a shareholder.
To be subject to personal jurisdiction in this state for purposes of the collection of income taxes, together with rela ted interest and penalties, imposed on the shareholder by this state with respect to the income of the S orporation.
I further certify that I am or have been a shareholder of said corporation during its taxable year.
Signature of Non-Resident Shareholder Date
Mississippi
Non-Resident Income Tax Agreement
This agreement shall be binding upon my heirs, representatives, assigns, successors, executors and administrators.
Address

• This form may be reproduced.
• Do not file this agreement with the S Corporation Tax Return.
• Reta in this agreement in your permanent tax files.

AGREEMENT
Tax Year Beginning Tax Year Ending
FEIN SSN mm dd yyyy mm dd yyyy