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S-4868

Application for Automatic Extension of Time

To File SPRINGFIELD Income Tax Return

____

TaxYear

Your first name and initial (if joint, also give spouse's name and initial)

Last name

Your social security number

Please

Type

Present home address (number and street or rural route) If P.O. Box, also give street address

Spouse's social security number

City, town or post office, state and ZIP code

Employer ID number

■

CORPORATION

PARTNERSHIP

ESTATE

EXTENSION IS

■

INDIVIDUAL

■

REQUESTED FOR:

CALENDAR YEAR FILER

FISCAL YEAR FILER

INSTRUCTIONS:

Prepare this form in duplicate. File the original with the Springfield Income Tax Division on or before the due date for

filing your return (if you wish to have an approved copy, you must enclose a stamped pre-addressed envelope in which it will

be returned.) Attach the duplicate to your Springfield Income Tax Return when filed.

{

When form S-4868 is filed timely, an automatic extension will be granted for INDIVIDUAL RETURNS until August 30 of

INDIVIDUAL

RETURNS

the year the return is due. The tentative tax must be paid with this application for extension.

When an extension of greater than four months is requested, the tax tentatively determined to be due must be paid by the

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last day of the forth month. The Uniform City Income Tax Ordinance limits the extension of time for filing annual returns to

SIX MONTHS from the due date.

CORPORATIONS

PARTNERSHIPS

ESTATES

A _______________ month extension of time for filing until _______________, 20_______ is hereby requested in which to

file the Springfield Tax Return as indicate above for the calendar year _______________ or the fiscal year beginning

_______________, 20_______ and ending _______________, 20_______.

TENTATIVE TAX COMPUTATION:

1. Tentative City of Springfield Income Tax ......................................................................... $ _____________

2. Less:

a. City Income Tax Withheld ..................................................$ _____________

b. Estimated Tax Paid to Springfield .......................................$ _____________

c. Other Credits.......................................................................$ _____________

d. Total Credits (add line a, b and c) .......................................................................... $ _____________

3. BALANCE DUE (line 1 less line 2d) ............................................................................... $ _____________

ANY BALANCE DUE MUST BE PAID WITH THIS APPLICATION

SIGNATURE AND VERIFICATION:

Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and

statements and to the best of my knowledge and belief, it is true, correct, and complete; if prepared by some-

one other than the taxpayer, I am authorized to prepare this form.

Signature of taxpayer: _____________________________________________Date: ____________________

Signature of spouse:_______________________________________________Date: ____________________

(If filing jointly, BOTH MUST sign)

Signature of preparer other than the taxpayer: ___________________________________________________

Date:

MAIL TO: SPRINGFIELD INCOME TAX, 601 AVENUE A, SPRINGFIELD, MI 49015-1499

(Make checks payable to: CITY TREASURER)

■

Your request for an Extension is:

APPROVED

DENIED

By: ________________________________________________________________

Income Tax Administrator

Date

Form S-4868 - Application For Automatic Extension Of Time To File Springfield Income Tax Return

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