GR-SS-4                                            City of Grand Rapids                                                             GR-SS-4 
PLEASE TYPE                                        INCOME TAX DEPARTMENT                                                            PLEASE TYPE 

OR PRINT                     Employer’s Withholding Registration                                                                    OR PRINT

 Part I. Identification and addresses of employer or certified professional employer organization
  1. Employer application                      2. Certified professional employer organization (CPEO) co-employer application
3. Complete company name (include, if applicable, Corp., Inc., LLC, etc.)                             4. Federal Employer Identification Number

5. Business name, assumed name or DBA (if used)                                                       6. Business phone number

              7. Enter street number and name (include apartment or suite number after street name)

LEGAL         8. Enter Address Line 2:
ADDRESS
              9. City                                                                             10. State   11. Zip Code

              12. Enter street number and name (include apartment or suite number after street name)

MAILING     13. Enter Address Line 2:
ADDRESS
              14. City                                                                            15. State   16. Zip Code

              17. Enter street number and name (include apartment or suite number after street name)
PHYSICAL 
ADDRESS OF    18. Enter Address Line 2:
PROJECT OR 
ACTIVITY      19. City                                                                            20. State   21. Zip Code
IN CITY

Part II. General information 
1. Date first wages subject to city withholding paid 1a.                      7. Reinstated old business; enter old FEIN7a.
2. Number of employees subject to city withholding 2a.                        8. Started "doing business" in city; enter date 8a.
3. Reasons for filing withholding registration                                9. CPEO with new client in the city. Enter client's FEIN on line 9a and
4. Started a new business; enter date              4a.                        complete  items 11 and 12 below 9a.
5. Incorporated an existing busines                                           10. Other (explain) 10a.
6. Purchased a going business (complete items 11 and 12 below)
11. Name of previous owner or PEO's client                                12. Will the previous owner or PEO's client continue to    12a. Yes
                                                                          x   have employees subject to city income tax withholding  12b. No
13. Does your tax year end in December 31                                            Month (MM) Day (DD)
  13a. Yes     13b. No  If no, provide the fiscal year end month and day         13c.

Part. III. Income tax withholding - Filing and payment of income tax withheld  
Check box below to indicate how withholding tax returns are prepared and filed
1. Our withholding tax returns are prepared in house, filed and paid          5. An IRC Section 3504 agent is authorized to prepare, file and pay
X   and all returns and Forms W-2 are filed and paid under our FEIN           X  our withholding tax returns and Forms W-2; all withholding tax
2. A common paymaster prepares our withholding tax returns:                   X  returns and Forms W-2 are filed under the agents FEIN. Attach a
X   Withholding tax is paid under FEIN  2a.                                   X  copy of federal Form 2678. ATTACH A COMPLETED FORM
X   Forms W-2 are filed under FEIN             2b.                            X  CF-2678 AS A PART OF THIS REGISTRATION
3. A payroll services provider prepares our withholding tax returns           6. A professional employer organization is authorized under a PEO
X   and Forms W-2. Returns and Forms W-2 are filed and paid under             X   agreement to prepare, file and pay our withholding tax returns
X  our FEIN                                                                   X   and Forms W-2 under their FEIN. Attach a copy of the PEO
4. A payroll reporting agent is authorized to prepare our withholding         X   agreement. A certified PEO must be registered with the city as a
X   tax returns and Forms W-2 which are filed and paid by the agent           X   co-employer liable for filing and payment of withholding tax
X  under our FEIN. Attach a copy of Form 8655 filed with the IRS.             7. We are a CPEO preparing, filing and paying or clients city
X   ATTACH A COMPLETED FORM CF-8655 AS PART OF THIS                           X   withholding tax under our FEIN. Attach a copy of the IRS
X   REGISTRATION                                                              X   certification.

 Complete company name (include, if applicable, Corp., Inc., LLC, etc.)                          Federal Employer Identification Number

 Part IV. Type of business ownership (Check all boxes that apply)
    1. Individual/Sole Proprietorship  (Identify owner in                   8. Michigan Corporation (Identify all corporation officers in
    X   Part III below)                                                     X   Part III below)
    2. General Partnership                                                     8a. Michigan Subchapter S Corporation
        X(Identify all partners in Part III below)                             8b. Michigan Professional Corporation
    3. Limited Partnership (LP)                                             9. Foreign (Non-Michigan) Corporation (Identify all corporation
    X   (Identify general partners in Part III below)                       X  officers in Part III below)
    4. Professional Limited Liability                                          9a.Foreign Subchapter S Corporation
    5. Partnership (LLP) (Identify all                                      10. Nonprofit Corporation (Identify all corporation officers in
    X   General Partners in Part III below)                                 X    Part III below)
    6. Limited Liability Company (LLC)                                      11. Government
    X   (Identify all members in Part III below)                            12. Estate  (Identify estate administrator or personal
    7. Professional Limited Liability Company (PLLC)                        X    representative in Part III below)
    X   (Identify all members in Part III below)                            13. Trust  (Identify trustee in Part III below)
                                                                            14. Other (explain)

 Part V. Identification of each owner, partner, member or corporate officer  (Attach Part VII if more than 2)
 1a.  Name (last, first middle, suffix)                                                         1g. Home Telephone Number

 1b. Business Title                                                                             1h. Date of Birth

 1c. Residence Address (street number and name including apartment number after street name)    1i. Social Security Number

 1d. City                                                 1e. State          1f. Zip Code       1j. Drivers License Number/ ST ID Number

 2a.  Name (last, first middle, suffix)                                                         2g. Home Telephone Number

 2b.  Business Title                                                                            2h. Date of Birth

 2c. Residence Address (street number and name including apartment number after street name)    2i. Social Security Number

 2d. City                                                 2e. State          2f. Zip Code       2j. Drivers License Number/ ST ID Number

 Part VI. Contact information 
1. Contact person for withholding tax questions                             2. E-mail address of contact person

3. Phone number for contact person above. 4a.

 Part VII. Signature area
 Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is 
 true, correct, and complete.
 1a. Signature (owner, member or officer who controls or is responsible for    1b. Title
X   filing withholding tax returns and paying the income tax withheld)

 1c. Type or print name of person signing above                                1d. Date                        Phone #

Mail to: Grand Rapids Income Tax Dept. PO Box 347 Grand Rapids, MI 49501-0347                   Phone 616-456-3415 option 4, fax 616-456-4540

Information collected on this form is confidential pursuant to MCL 141.674(1), Michigan Uniform City Income Tax Ordinance; Sec.74(1).  
Information gained by the administrator, city treasurer or any other city official, agent or employee as a result of a return, investigation, 
hearing or verification required or authorized by this ordinance is confidential, except for official purposes in connection with the 
administration of the ordinance and except in accordance with a proper judicial order. 

GR-SS-4 Questions about this application?  Call the Income Tax Department at (616) 456-3415                     Option 4 email 
grwhtax@grcity.us.