Form Gr-4868 - Application For Automatic Extension Of Time To File An Individual Income Tax Return - City Of Grand Rapids

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GR-4868
GRAND RAPIDS
2011
APPLICATION FOR AUTOMATIC EXTENSION OF TIME
TO FILE AN INDIVIDUAL INCOME TAX RETURN
Date to file by:
4/30/2012, the due date of the return for the 2011 tax year.
Payment:
$
Payment Method:
Make payment by check or money order payable to "Treasurer, City of GRAND RAPIDS." Include your SS
daytime phone number, and 2011 Form GR-4868 on your check or money order. DO NOT SEND CASH.
To pay by credit card or direct debit, see income tax website of the City of GRAND RAPIDS. Not all cities
accept credit card or direct debit payments.
Address for Payment:
GRAND RAPIDS
PO Box 108 Grand Rapids, MI 49501-0108
Other Instructions:
An extension to file does not extend the time to pay the tax.
The extension is automatically granted upon payment of the tentative tax balance due.
Failure to pay the balance due (the tentative tax due) invalidates the extension request.
An extension filed without a payment will not be accepted.
The City Income Tax Ordinance limits the extension of time for filing annual returns to SIX months from
the original due date.
The filing of federal Form 4868, Application for Automatic Extension of Time to File U.S. Individual
Income Tax return, with the Internal Revenue Service, does not grant an extension of time to file a city
return.
Where the federal Internal Revenue Code grants an automatic two-month extension to persons living
outside the United States, an automatic two-month extension will be granted.
Interest and penalty is charged on taxes paid late even if an extension of time to file is granted.
Penalty may be waived by the Income Tax Administrator if the tax paid by the original due date
is not understated by more than 5% of tax or the taxpayer can show that the failure to pay on
time was due to reasonable cause.
Taxpayer Records:
Amount Paid:
Check Number:
Date Mailed:
Revised: 01/20/2012
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DETACH HERE
GR-4868
GRAND RAPIDS
2011
APPLICATION FOR AUTOMATIC EXTENSION OF TIME TO FILE AN INDIVIDUAL INCOME TAX RETURN
Taxpayer's first name, Initial, last name
Taxpayer's SSN
If joint return, spouse's first name, Initial, last name
Spouse's SSN
Present home address (Number and street)
Apt. no.
TENTATIVE TOTAL TAX IS A REASONABLE ESTIMATE OF THE TAX
REQUIRED TO BE REPORTED ON THE TAX RETURN FOR THE TAX YEAR
Address line 2 (P.O. Box address form mailing use only)
.00
1. Tentative total tax
City, town or post office
State
Zip code
2. Total payments and credits
.00
Foreign country name, province/county, postal code
3. Tentative tax balance due
.00

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