RefeR to instRuctions on back to see who can use this foRm
ATTACH A COPY OF THE FRONT OF FEDERAL 1040 FORM
BR 1040EZ
INDIVIDUAL RETURN 2016
Due Date: april 30, 2017
a. First name and initial last name Your Social Security number B. RESiDEnCY
RESiDEntinside City limits n
if Joint First name of Spouse Spouse’s Social Security number nOn-RESiDEnt
township of 
n Big Rapids          n green
Present home address n Colfax               n grant
n Barton                n norwich
City, State and Zip Code n home                 
n Other_______________________
(Please specify)
C. Filing StatuS D. EXEMPtiOnS
a. _____ Single                                         D. name of Deceased: number______________________x $600.00 = $______________
B. _____ Married, Filing Jointly                   __________________________________ if you are claimed as a dependent on someone else’s Big Rapids return, check
C. _____ Married, Filing Separately this box and do not take the exemption. n
PLACE ADDITIONAL FORMS BEHIND AND STAPLE HERE 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. n

HERE 1.  total Wages, Salaries, and tips......................................................................................................................       1.                                          00

2.  interest and/or Dividends income ..................................................................................................................       2.                                          00

& 1099’s
3.  Exemptions (From D above) ............................................................................................................................         3.                                                        00
(if you are a student and your parents do not file a City of Big Rapids return, check this box n and claim yourself)

4.  taxable income (line 1 + line 2 - line 3) ......................................................................................................       4.                                          00

5.  tax (multiply amount on line 4 by one of the following)..................................................................................       5.                                          00

a: RESiDEnt OnlY -1% (.01)
B: nOn-RESiDEnt OnlY - 1/2% (.005)
STAPLE COPY OF W-2’s 6.  Voluntary Contribution to Big RaPiDS COMMunitY POOl and/or COMMunitY liBRaRY (Please circle) ..       6.                                          00

7.  total of lines 5 and 6 ....................................................................................................................................       7.                                          00
OFFiCE uSE OnlY
Payment received
8.  tax Withheld                                                                                          00 with Return
2016 Estimated Payments                                                                     00 ______________________
______________________
Credit from previous year over payment                                                 00 ______________________
                                                                                                     total Payments                                        00
9.  tax Due (line 7 minus line 8) ........................................................................................................................      9.                                           00

10.  Penalty and interest......................................................................................................................................     10.                                          00

11.  Balance Due ................................................................................................................................................     11.                                          00
ENCLOSE CHECK - DO NOT STAPLE
12.  Overpayment /amount of Refund (line 8 minus line 7)................................................................................     12.                                          00
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______________________________

SIGN 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

         INSTRUCTIONS FOR FORM BR 1040EZ

         Use This Form If:
WHO CAN
USE THIS
         You were a Resident of Big Rapids for all of 2016 with income from wages,
FORM
         interest or dividends.

         You were a Non-Resident of Big Rapids for all of 2016 with wages earned in Big
         Rapids and none of the earnings from Big Rapids employees is excluded from
         Big Rapids Income Tax.

         Place a check mark in the Resident or Non-Resident township area. A part-year
RESIDENCY
         resident of Big Rapids cannot use this form.
STATUS

         If you have income on your Federal Income Tax Return that is not taxable by
INCOME
         Big Rapids, use Form BR 1040.

         Total Wages, Salaries and Tips.
LINE 1   Residents: Total from Box 1 of all your W-2 forms.
         Non-Residents: Total from Box 1 of all the W-2 forms for work done in the City
         of Big Rapids.

         Attach your W-2 forms on the front of form BR 1040EZ

LINE 2   Residents: Report all taxable interest and dividend income.
         Non-Residents: Leave blank, interest and dividend income is not taxable to a
         Non-Resident.

LINE 10  This schedule applies to both residents and non-residents who file their return
         after the due date of April 30, 2017 and owe tax liability.

              A. Interest - .0001233 per day                                      A.________________
              B. Penalty - 1% of the amount of the unpaid
         tax for each month of fraction thereof not
         to exceed a total penalty of 25% of the
         unpaid tax.                                                                B.________________
              C. Total penalty and interest, but must pay a 
         minimum of $2.00
         Enter on BR 1040EZ, Line 10                                  C. ______________