GR-4868                                                          GRAND RAPIDS                                               2016 RET REX
                                           APPLICATION FOR AUTOMATIC EXTENSION OF TIME 
                                                        TO FILE AN INDIVIDUAL INCOME TAX RETURN

Taxpayer Name:
Social Security No:
File on or Before:                        4/30/2017, due date of 2016 return.*
Payment:                                  $

Payment Method:           • Make payment by check or money order payable to "City of Grand Rapids." DO NOT SEND CASH.
                          • Write your Soc. Sec. No., daytime phone number and "2016 GR-4868" on check or money order. 
                          • To pay by credit card or direct debit, see income tax website of the City of Grand Rapids. 

Address for Payment:                      Grand Rapids Income Tax Department
                                          PO Box 108
                                          Grand Rapids, MI  49501-0108

Instructions:             • An extension to file does not extend the due date to pay tax. Tax paid late will be assessed late fees.
                          • Line 1: Enter the total tax liability you expect to report on your 2016 Form GR-1040, page 1, line 23.
                          • Line 2: Enter the total payments that you expect to report on your 2016 Form GR-1040, page 2, line 4, 
                                          not including the extension payment reported on line 3 of this form.
                          • Filing date: The income tax ordinance limits an extension to SIX months from the original due date.

Related Information:      • Federal extension: Filing a federal extension (Form 4868) with the Internal Revenue Service does not 
                                          grant an extension of time to file a Grand Rapids income tax return.
                          • Persons living outside the United States: Where the Internal Revenue Code grants an automatic two-
                                          month extension to persons living outside the U.S., an automatic two-month extension will be granted.

Payment:                  • An extension is automatically granted upon payment of the balance due (line 3); failure to pay the 
                                          balance due invalidates the extension request; an extension filed without a payment will not be accepted.
                          • Interest and penalty will be assessed on taxes paid late even if an extension of time to file is granted.
                          • Penalty may be waived by the Income Tax Administrator if the tax paid by the original due date is not 
                                          understated by more than 5% of tax or the taxpayer can show that the failure to pay on time was due to 
                                          reasonable cause.
* Due Date                • If the due date falls on a Saturday, Sunday or holiday, the due date is the next business day.

Taxpayer Records:                         Amount Paid:                  Check Number:                          Date Mailed: 
                                                                                                                            Revised: 04/21/2015
       KEEP TOP PORTION FOR YOUR RECORDS.  SEND BOTTOM PORTION WITH YOUR PAYMENT 
                                                                 v   DETACH HERE  v
GR-4868                                                          GRAND RAPIDS                                               2016 RET REX
        APPLICATION FOR AUTOMATIC EXTENSION OF TIME TO FILE AN INDIVIDUAL INCOME TAX RETURN
                                                                Mail  To:  Grand Rapids Income Tax Department
                                                                 PO Box 108
NACTP #                                                          Grand Rapids, MI  49501-0108
EFIN #                                                                                                                      Revised: 04/21/2015
Taxpayer's first name, initial, last name                        Taxpayer's SSN

If joint return spouse's first name, initial, last name          If joint payment, spouse's SSN

Present home address (Number and street)                Apt. no. Payment voucher 2D barcode

Address line 2 (P.O. Box address for mailing use only)

City, town or post office                  State        Zip code
                                                                  1.  Estimate of total tax liability for 2016                                 .00
Foreign country name, province/county, postal code                2.  Total 2016 payments and credits                                          .00
                                                                  3.  Balance due (Line 1 less line 2)                                         .00