Form PH-4868                                                  CITY OF PORT HURON 
                                                                                                                       NOTE: If your return will show a 
  (Also known as Form PH-4267)               APPLICATION FOR EXTENSION OF TIME 
                                                                                                                       refund, you do not need to file 
                                               TO FILE A CITY INCOME TAX RETURN 
  (Revised 11/20)                                                                                                      this form - see the instructions 
          Taxpayers name(s) 
  Please  
  Type    Address of taxpayer (number, street and apartment number, or rural route) 
  or      
  Print   City, town or post office, state, and ZIP code 

                                           This is not an extension of time to pay your tax 
                                                                                Individual's social security number  If filing joint, enter spouses SSN 
  Check only ONE box. File a separate request for each return.                                                       

     Individual return (PH-1040)               Fiduciary return (PH-1041) 
                                                                                Federal identification number (all other entities) 
     Corporation return (PH-1120)              Partnership return (PH-1065) 
  Extension is for the tax year ending:                                      Length of extension requested (6 month maximum): 

  1. Total city tax liability for the year                                                                             1.                                       
                                                                                                                      
  2. City of Port Huron tax withheld (individuals)                                                                     2.                                       
                                                                                                                      
  3. Estimated payments to date (include any prior year overpayment carried forward)                                   3.                                       
                                                                                                                      
  4. Other credits and payments                                                                                        4.                                       
                                                                                                                      
  5. Add lines 2, 3 and 4                                                                                              5.                                       
 
  6. BALANCE DUE    Subtract line 5  from line 1.  If  zero or less, enter -0-                                         6.                                       
 
                               To get this extension, you MUST pay the balance due with this form. 
                  Make remittance payable to "City of Port Huron. " Write the type of tax and identification number on the remittance 
          Mail to: Income Tax Division, City of Port Huron, 100 McMorran Blvd., Port Huron, MI 48060 
  I declare, under penalty of perjury, that the information in this application and any attachments, is true and complete to the best of my knowledge. 
 
  X                                                                          X                                                                                  
  Filer's signature                                       Date                 Spouse's signature (if filing a joint individual return) Date 
                                                                                                                                    
  X                                                                                                                                 
  Preparer's signature (other than taxpayer)                                                                                            Date 
                                                                                                                                                                
  If correspondence regarding this extension is to be sent to you at an address other than the one shown above or to an agent acting for you, please enter the 
  name of the agent and/or the address where it should be sent. 
          Name 
  Please 
  Type    Address (number, street and apartment number, or rural route) 
  or 
          City, town or post office, state and ZIP code 
  Print 

 INSTRUCTIONS FOR FILING AN APPLICATION FOR EXTENSION 
 OF TIME TO FILE A CITY OF PORT HURON INCOME TAX RETURN 
 
 The City of Port requires all taxpayers to pay     interest is $2.00. We will waive the penalty 
 the full amount of tax owed on or before the       charges if you can show that the reason you 
 due date of their return. An extension of          did not pay the full amount by the due date 
 time to file is NOT an extension of time to        was due to reasonable cause. 
 pay the tax. If you cannot pay the balance         
 due by the due date of your return, you must       Make all checks payable to: City of Port Huron. 
 sign a payment schedule. We will assess            Write the last four numbers of your Social Security 
 penalty and interest charges on all amounts        number or your FEIN on your payment and note 
 remaining unpaid after the due date of the         what the payment is for. Mail your signed 
 return.                                            application for extension and remittance to: 
                                                    
 When you file an extension request, if you find    City of Port Huron 
 that more income tax will be due to the City,      Income Tax Division 
 you must pay that amount with this form. We        100 McMorran Boulevard 
 will not consider your application a valid         Port Huron, MI 48060 
 extension unless you pay the total balance         
 due.                                               The City of Port Huron’s Income Tax 
                                                    Administrator requires payment of all amounts 
 If you find that no additional tax will be due to  due before we will grant an extension under 
 the city, you do not need to file this form. A     Sec. 64 of the Uniform City Income Tax 
 copy of your federal extension attached to         Ordinance (Public Act 284 of 1964, State of 
 your return will be sufficient. Attach a copy of   Michigan, as amended). The Administrator 
 all federal and City of Port Huron extensions      deems this extension to meet the 
 to your city return when you file it.              requirements for filing a tentative return under 
                                                    Sec. 64 of the Uniform City Income Tax 
 Your application for extension must be             Ordinance. 
 postmarked on or before the original due date   
 of your return.                                    If you have any questions regarding this 
                                                    extension or the City of Port Huron income 
 If you do not pay the full amount of tax due       tax, please call(810) 984-9741. You can also 
 with your application for extension, we will       visit our office in Room 112 of the Municipal 
 assess you interest and penalty on the unpaid      Office Center, 100 McMorran Boulevard, Port 
 amount. File your return and pay the balance       Huron, Michigan 48060. 
 shown due with the return. Our office will bill 
 any interest and penalty charges, based on 
 the date you paid the balance. 
 
 We will assess you monthly interest charges 
 on any unpaid balance. The monthly interest 
 rate is 1/12 of the legally prescribed rate (1% 
 above the prime rate, as determined by the 
 Michigan Department of Treasury). 
 
 We will also assess a penalty of 1% of the 
 balance due per month, for each month the 
 payment is late. The total penalty will not 
 exceed 25% of the balance due. The 
 minimum combined charge for penalty  and