Form 72-900-21-1-1-000 (Rev. 04/21)
Name:
DBA:
FEIN:
ZipCity
Mailing Address (Number & Street, Including Rural Route)
State
SSN:
Date Phone
Signature of Taxpayer or Agent
729002111000
The conditions of this bond require that the taxpayer comply with all provisions of the Laws, Rules and Regulations of the
State of Mississippi pertaining to Mississippi sales tax, and pay all sales taxes, penalties, and interest as required by the
Laws, Rules and Regulations of the State of Mississippi.
Upon termination of the business or revocation of permit and upon determination by the Department of Revenue of the
State of Mississippi that all sales taxes, penalties, interest and other expenses due the State of Mississippi have been
paid, the balance of the money deposited shall be refunded to taxpayer.
Mississippi
Sales Tax Cash Bond
Or
Sales Account ID:
The above taxpayer has deposited with the Department of Revenue, the sum of FIVE HUNDRED Dollars ($500.00) as a
Sales Tax Cash Bond.
(Example:9999-9999)
If making payment by check or money order sent separately, please provide check #:
Please reference SSN or FEIN on check(s) or other correspondence sent to the above address.
Permit Location Number:
(Example:999-99999-9)
Miss. Code Ann. Section 27-65-27, as amended, requires that every person desiring to engage in business within this
state, who maintains no permanent place of business within the state, and of every person desiring to engage in the
business of making retail sales of mobile homes, a cash bond or an approved surety bond in an amount sufficient to cover
twice the estimated tax liability for a period of three (3) months and the taxpayer is intending to engage in the business of:
Checks should be mailed to your designated District Office listed on the second page.
Hancock,Harrison,Jackson
GulfCoastDistrictOffice
1141BayviewAve.,Ste.400
Biloxi,MS39530‐1601
Ph:(228)436‐0554
Fax:(228)436‐0964
Amite,Covington,Forrest,George,Greene,
JeffersonDavis,Jones,Lamar,Lawrence,
Marion,PearlRiver,Perry,Pike,Stone,
Walthall
HattiesburgDistrictOffice
P.O.Box1709
Hattiesburg,MS39403‐1709

17JMTatumIndustrialDr.,Ste.2
Hattiesburg,MS39401

Ph:(601)545‐1261
Fax:(601)584‐4051
Alcorn,Benton,Bolivar,Calhoun,Carroll,
Chickasaw,Clay,Coahoma,DeSoto,Grenada,
Itawamba,Lafayette,Lee,Leflore,Marshall,
Monroe,Montgomery,Panola,Pontotoc,
Prentiss,Quitman,Sunflower,Tallahatchie,
Tate,Tippah,Tishomingo,Tunica,Union,
Webster,Yalobusha,andthefollowingcities
inTN:
Arlington,Bartlett,Collierville,Germantown,
Memphis,Millington
HernandoDistrictOffice
2631MclngvaleRoadSte116
Hernando,MS38632

Ph:(662)449‐5150
Fax:(662)449‐5163
Adams,Claiborne,Copiah,Franklin,Hinds,
Holmes,Humphreys,Issaquena,Jefferson,
Lincoln,Madison,Rankin,Sharkey,Simpson,
Warren,Washington,Wilkinson,Yazoo
JacksonDistrictOffice
P.O.Box1033
Jackson,MS39215‐1033

500ClintonCenterDr.
Clinton,MS39056

Ph:(601)923‐7300
Attala,Choctaw,Clarke,Jasper,Kemper,
Lauderdale,Leake,Lowndes,Neshoba,
Newton,Noxubee,Okibbeha,Scott,Smith,
Wayne,Winston
MeridianDistrictOffice
P.O.Box5794
Meridian,MS39302

900AHighway19South
Meridian,MS39301

Ph:(601)483‐2273