Form Br 1040ez - Attach To 1040 Form - Individual Return - 2010

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REFER TO INSTRUCTIONS ON BACK TO SEE WHO CAN USE THIS FORM
ATTACH A COPY OF THE FRONT OF FEDERAL 1040 FORM
BR 1040EZ
2010
INDIVIDUAL RETURN
Due Date: April 30, 2011
Last Name
Your Social Security Number
B. RESIDENCY
A. First Name and Initial
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RESIDENT
Inside City Limits
NON-RESIDENT
If Joint First Name of Spouse
Spouse’s Social Security Number
Township of
Big Rapids
Green
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Present Home Address
Colfax
Grant
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Barton
Norwich
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Home
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City, State and Zip Code
Other_______________________
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(Please specify)
D. EXEMPTIONS
C. FILING STATUS
Number______________________x $600.00 = $______________
A. _____ Single
If you are claimed as a dependent on someone else’s Big Rapids return, check
B. _____ Married, Filing Jointly
this box and do not take the exemption.
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C. _____ Married, Filing Separately
Spouse’s Name__________________________________________________
If you are a FSU student with permanent home other than Big Rapids, check
Social Security Number __________________________________________
this box and claim yourself.
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00
1. Total Wages, Salaries, and Tips......................................................................................................................
1.
00
2. Interest and/or Dividends Income ..................................................................................................................
2.
00
3. Exemptions
............................................................................................................................
3.
(From D above)
(if you are a student and your parents do not file a City of Big Rapids return, check this box
and claim yourself)
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00
4. Taxable Income (Line 1 + Line 2 - Line 3) ......................................................................................................
4.
00
5. Tax (multiply amount on Line 4 by one of the following)..................................................................................
5.
A: RESIDENT ONLY -1% (.01)
B: NON-RESIDENT ONLY - 1/2% (.005)
00
6. Voluntary Contribution to BIG RAPIDS COMMUNITY POOL and/or COMMUNITY LIBRARY (Please circle) ..
6.
00
7. Total of Lines 5 and 6 ....................................................................................................................................
7.
OFFICE USE ONLY
Payment received
8. Tax Withheld
00
with Return
______________________
2010 Estimated Payments
00
______________________
Credit from previous year over payment
00
______________________
Total Payments
00
00
9. Tax Due (Line 7 minus Line 8) ........................................................................................................................
9.
00
10. Penalty and Interest......................................................................................................................................
10.
00
11. Balance Due ................................................................................................................................................
11.
00
12. Overpayment /Amount of Refund (Line 8 minus Line 7)................................................................................
12.
I declare, under penalty of perjury, that the information on this return and attachments is true and complete.
I authorize the City to discuss my
DO NOT discuss my
I declare, under penalty of perjury, that this return
claim and attachments with my
claim with my preparer.
is based on all information of which I have knowledge.
preparer
Filer’s Signature ______________________________________________ Date __________________
PREPARER’S SIGNATURE & ADDRESS
Birthdate ______________________________
Spouse’s Signature ____________________________________________ Date __________________
Birthdate ______________________________
Phone (
)_______________________________
MAIL YOUR RETURN FOR REFUND TO: CITY OF BIG RAPIDS, INCOME TAX DIVISION, 226 NORTH MICHIGAN AVE., BIG RAPIDS, MI 49307
MAIL YOUR RETURN FOR PAYMENT TO: CITY OF BIG RAPIDS, TREASURER’S OFFICE, 226 NORTH MICHIGAN AVE., BIG RAPIDS, MI 49307

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