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

RefeR to instRuctions on back to see who can use this foRm

ATTACH A COPY OF THE FRONT OF FEDERAL 1040 FORM

BR 1040EZ

2012

INDIVIDUAL RETURN

Due Date: April 30, 2013

last name

your social security number

B. ResiDency

A. first name and initial

ResiDenT

inside city limits

nOn-ResiDenT

if Joint first name of spouse

spouse’s social security number

Township of

Big Rapids

Green

Present home Address

colfax

Grant

Barton

norwich

home

city, state and Zip code

Other_______________________

(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.

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.

1. Total Wages, salaries, and Tips......................................................................................................................

2. interest and/or Dividends income ..................................................................................................................

3. exemptions

............................................................................................................................

(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)

4. Taxable income (line 1 + line 2 - line 3) ......................................................................................................

5. Tax (multiply amount on line 4 by one of the following)..................................................................................

A: ResiDenT Only -1% (.01)

B: nOn-ResiDenT Only - 1/2% (.005)

6. Voluntary contribution to BiG RAPiDs cOMMUniTy POOl and/or cOMMUniTy liBRARy (Please circle) ..

7. Total of lines 5 and 6 ....................................................................................................................................

Office Use Only

Payment received

8. Tax Withheld

with Return

______________________

2012 estimated Payments

______________________

credit from previous year over payment

______________________

Total Payments

9. Tax Due (line 7 minus line 8) ........................................................................................................................

10. Penalty and interest......................................................................................................................................

10.

11. Balance Due ................................................................................................................................................

11.

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 __________________