City of Portland 

                                        Income Tax Department 
P-SS-4
                                               1.             FEDERAL EMPLOYER IDENTIFICATION NUMBER
Employer’s Withholding Registration

2. Complete Company Name (Include, if applicable, Corp., Inc., L.L.C., etc.)

3. Business Name, Assumed Name of DBA (If used)

   LEGAL         4A. Enter Number and Street (Address to which correspondence is mailed.) Business Telephone 
ADDRESS 
                 City, State, Zip 

   MAILING       4B. Enter Number and Street. (Address to which tax forms are mailed.) 
ADDRESS 
                 City, State, Zip 
PHYSICAL         4C  Enter Number and Street. (Address of physical location in the City of Portland.) 
ADDRESS IN 
PORTLAND         City, State, Zip 
Complete all information for each owner, partner, member or corporate officer.  Attach a separate list if necessary. 
5A.  Name (Last, First, Middle Initial)        Home Telephone 

Business Title                                 Date of Birth 

Residence Address (Number, Street)             Social Security Number 

City, State, Zip                               Driver License/Michigan Identification 

5B. Name(Last, First, Middle Initial)          Home Telephone  

Business Title                                 Date of Birth 

Residence Address (Number, Street)             Social Security Number 

City, State, Zip                               Driver License/Michigan Identification 

COMPLETE THIS REGISTRATION IF REQUIRED TO WITHHOLD OR VOLUNTARILY WITHHOLDING AND: 
   1) Started a new business; or
   2) Reinstated an old business; or
   3) Purchased an ongoing business; or
   4) Started doing business in Portland; or
   5) Changed the type of business ownership (eg: from sole proprietorship to partnership, incorporating a sole
      proprietorship or partnership)
EMPLOYERS REQUIRED TO REGISTER AND WITHHOLD: 
   1) Employers having a location in the City of Portland; or
   2) Employers doing business in the City of Portland even though they have no location in the City.
WITHHOLD TAX FROM WAGES PAID TO THE FOLLOWING EMPLOYEES: 
   1) All residents of the City of Portland whether or not they work in the city;
   2) All non-residents of the City of Portland who work in Portland (withhold only on wages earned in Portland)
For further information refer to the Income Tax Ordinance or call the Income Tax Department at (517) 647-2941. 
Tax Forms are also on our website, www.portland-michigan.org. 

6. TYPE OF BUSINESS OWNERSHIP  (CHECK ONE ONLY)

    
     (1) Individual
    
     (2) Partnership
    
     Registered Partnership Agreement Date:________
    
     Limited Partnership
          Identify all general partners above.
    
     (3) Limited Liability Co.
    
     (4) Corporation
    
     Sub Chapter S
    
     Professional
    
     (5) Non-Profit Corporation
    
     (6) Government
    
     (7) Trust or Estate (Fiduciary)
    
     (8) Other (Explain)______________________________________________

State of Incorporation                                                    Michigan Corporation Number 

7. DATE YOU FIRST PAID WAGES SUBJECT TO PORTLAND                          CONTACT PERSON FOR WITHHOLDING TAX 
WITHHOLDING                                                               QUESTIONS (NAME AND PHONE) 
NUMBER OF EMPLOYEES SUBJECT TO PORTLAND WITHHOLDING 

8. REASON FOR REGISTRATION
    
      Started a new business on ____________________ 
    
     Incorporated an existing business 
    
     Purchased a going business.  Complete item 9 below. 
    
     Reinstated an old business.  Old account no.___________________ 
    
     Started doing business in Portland 
    
     Other (explain)  _____________________________________________ 

9. NAME OF PREVIOUS OWNER OF CORPORATION
WILL THE PREVIOUS OWNER CONTINUE TO HAVE EMPLOYEES SUBJET TO THE PORTLAND INCOME TAX WITHHOLDING?  
              
   YES 
              
   NO 
10. DO YOU CLOSE YOUR BOOKS FOR TAX PURPOSES (FOR THE YEAR) ON DECEMBER 31 ?ST

11. SIGNATURE (of the officer or owner who controls or is responsible for TITLE 
filing Returns, and making payments of Portland taxes.)

TYPE OR PRINT NAME                                                        DATE 

SIGNATURE                                                                 TITLE 

TYPE OR PRINT NAME                                                        DATE 

                                                                                Revised 10/2012 
P-SS-4
Questions on this application?  Call the Income Tax Department at (517) 647-2941

Mail To:          City of Portland 
                  Income Tax Department 
                  259 Kent Street 
                  Portland, MI  48875