Form 5120 - City Of Detroit Part Year Resident Income Tax Return - 2016 Page 3

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2016 Form 5120, Page 3

Filer’s Full Social Security Number

City of Detroit Part-Year Resident Income Tax Return

PART 6: AMENDED RETURN

45.

Reason for amending:

PART 7: CERTIFICATION

Deceased Taxpayer.

Preparer Certification.

If Filer and/or Spouse died after December 31, 2015, enter dates below.

I declare under penalty of perjury that

ENTER DATE OF DEATH ONLY.

this return is based on all information of which I have any knowledge.

Example: 04-15-2016 (MM-DD-YYYY)

Preparer’s PTIN, FEIN or SSN

Filer

Spouse

Preparer’s Name (print or type)

Taxpayer Certification.

I declare under penalty of perjury that the information in this return

and attachments is true and complete to the best of my knowledge.

Filer’s Signature

Date

Preparer’s Business Name, Address and Telephone Number

Spouse’s Signature

Date

By checking this box, I authorize the Michigan Department of Treasury to discuss

my return with my preparer.

Refund or zero returns. Mail your return to:

Michigan Department of Treasury, Lansing, MI 48956

Pay amount on line 41. Mail your check and return to: Michigan Department of Treasury, Lansing, MI 48929

Make your check payable to “State of Michigan - Detroit.” Print the last four digits of your Social Security number and “2016 Detroit Income Tax” on

the front of your check. If paying on behalf of another taxpayer, write the filer’s name and the last four digits of the filer’s Social Security number on

the check. Do not staple your check to the return. Keep a copy of your return and supporting schedules for six years. To check your refund status, have a

copy of your Form 5120 available when you visit

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