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Michigan Department of Treasury
4 (Rev. 9-03)
Application for Extension of Time to File Michigan Tax Returns
Issued under authority of P.A. 301 of 1939, 281 of 1967 and 228 of 1975. See instructions for filing requirements.
An extension of time to file is not an extension of time to pay. Type or print in blue or black ink.
PART 1: IDENTIFICATION
4
4
1. Check ONLY ONE box. File a separate request for each tax.
2. Federal Employer Identification Number or TR Number
Single Business Tax Return
*Income Tax Return
4
3. Social Security Number
If joint, enter spouse's number
* DO NOT file this form if a
*Fiduciary Return
refund will be shown on return.
4
4
4. Mailing Address
5. Taxpayer's name and address (if different from item 4)
PART 2: COMPUTATION AND PAYMENT OF TAX DUE
.00
6.
Total annual tax liability for the year
4
6.
7.
Payments made to date (include withholding, estimated tax
.00
payments and amounts carried forward)
7.
.00
8.
Credits (if any)
8.
.00
9.
Add lines 7 and 8
9.
.00
10.
Estimated balance due. Subtract line 9 from line 6
10.
.00
11.
Amount paid with this request
4
11.
PART 3: EXTENSION REQUEST
4
.
12
Month and year your tax year ends:
(Example: MM/YY)
4
13.
Check this box if federal extension is attached.
14.
Reason for extension:
15.
Check this box if Treasury has previously granted an extension for this tax year; attach a copy of the approved extension.
Submit this paper form even if you TeleFiled or e-filed an extension with your federal return.
Make checks payable to "State of Michigan" and write the type of tax and the FEIN or Social Security number on the payment.
Mail to: Michigan Department of Treasury, P.O. Box 30207, Lansing, MI 48909.
I declare under penalty of perjury that this return is based on all
I declare under penalty of perjury that the information in this return and attachments is true and
information of which I have any knowledge.
complete to the best of my knowledge.
4
4
Preparer's SSN, PTIN or FEIN
I authorize Treasury to discuss my return with my preparer.
Yes
No
Filer's Signature
Date
4
Preparer's Name and Address
Spouse's Signature
Date
See instructions.