GR-W-3                                  CITY OF GRAND RAPIDS                                    Year 
     EMPLOYER'S ANNUAL RECONCILIATION OF INCOME TAX WITHHELD
 1. Employer's, IRC Sec. 3504 agent's or CPEO's name                         6. Federal employer identification number

 2. Address (number, street and room or suite number)                        7. Due on or before
                                                                             February 28 each year
 3. City, state and zip code                           4. State  5. Zip code
                                                                                                Revised 10/15/2015

 8a. If line 1 is a Sec. 3504 agent or a CPEO, enter client employer's name  8b.FEIN of employer listed on line 8a

               SUMMARY OF TAX WITHHELD AND WITHHOLDING TAX PAID
              MONTH/QUARTER                            TAX WITHHELD                    WITHHOLDING TAX PAID
01M    January 
02M    February
01Q    March/First Quarter
       FIRST QUARTER TOTAL                             
04M    April
05M    May
02Q    June/Second Quarter
       SECOND QUARTER TOTAL                            
07M    July
08M    August
03Q    September/Third Quarter
       THIRD QUARTER TOTAL                             
10M    October
11M    November
04Q    December/Fourth Quarter
       FOURTH QUARTER TOTAL                            

  9. TOTAL WITHHOLDING TAX PAID (Sum of withholding tax       
X    payments reported in column above)                                              9.
10. NUMBER OF FORMS W-2 ATTACHED                                              10.
11. TOTAL TAX WITHHELD PER FORMS W-2                                          11.
12. BALANCE DUE (Line 9 less line 11)                                         12.
13. OVERPAYMENT (Line 11 less line 9) *ATTACH EXPLANATION                     13.

       * Submit a letter to request a refund. Include a detailed explanation on the                                       
     cause of the overpayment. Refunds will not be issued without an explanation.
Attach Forms W-2 (elctronic format or paper copy) and payment of any balance due (line 12.)
                             Listings are not accepted. 
Under penalties of perjury, I declare that I have examined this return and accompanying 
documents and, to the best of my knowledge and belief, they are true, correct, and complete.
14. SIGNATURE                 15. NAME AND TITLE (PLEASE PRINT)             16. DATE            17. PHONE NUMBER

Enclose the required copies of Forms W-2 and, if necessary, payment of any balance due and/or 
request for refund if needed.
Questions?    Phone: 616-456-3415 option 4            Email: grwhtax@grcity.us
Mail to:Grand Rapids Income Tax Department
     PO BOX 347
     GRAND RAPIDS MI 49501-0347