Form PH-4868                                                  CITY OF PORT HURON 
                                                                                                                  NOTE: If your return will show a 
(Also known as Form PH-4267)               APPLICATION FOR EXTENSION OF TIME 
                                           TO FILE A CITY INCOME TAX RETURN                                       refund, you do not need to file 
(Revised 1 /2 )0 2                                                                                                this form - see the instructions 
       Taxpayers name(s) 
Please 
Type   Address of taxpayer (number, street and apartment number, or rural route) 
or 
Print  City, town or post office, state, and ZIP code 

                                         This is not an extension of time to pay your tax 
                                                                              Individual's social security number If filing joint, enter spouses SSN 
Check only ONE box. File a separate request for each return. 

   Individual return (PH-1040)             Fiduciary return (PH-1041) 
                                                                              Federal identification number (all other entities) 
   Corporation return (PH-1120)            Partnership return (PH-1065) 
Extension is for the tax year ending:                                   Length of extension requested (6 month maximum): 

1. Total city tax liability for the year                                                                          1.  

2. City of Port Huron tax withheld (individuals)                                                                  2.  

3. Estimated payments to date (include any prior year overpayment carried forward)                                3.  

4. Other credits and payments                                                                                     4.  

5. Add lines 2, 3 and 4                                                                                           5.  

6. BALANCE DUE     Subtract line 5  from line 1.  If  zero or less, enter -0-                                     6.  

                             To get this extension, you MUST pay the balance due with this form. 
                   Make remittance payable to "City of Port Huron. " Write the type of tax and identification number on the remittance 
       Mail to: Income Tax Division, City of Port Huron, 100 McMorran Blvd., Port Huron, MI 48060 
I declare, under penalty of perjury, that the information in this application and any attachments, is true and complete to the best of my knowledge. 

X                                                                       X 
Filer's signature                                     Date                    Spouse's signature (if filing a joint individual return) Date 

X 
Preparer's signature (other than taxpayer)                                                                                             Date 

If correspondence regarding this extension is to be sent to you at an address other than the one shown above or to an agent acting for you, please enter the 
name of the agent and/or the address where it should be sent. 
       Name 
Please 
Type   Address (number, street and apartment number, or rural route) 
or 
       City, town or post office, state and ZIP code 
Print 

INSTRUCTIONS FOR FILING AN APPLICATION FOR EXTENSION 
OF TIME TO FILE A CITY OF PORT HURON INCOME TAX RETURN 

The City of Port requires all taxpayers to pay    interest is $2.00. We will waive the penalty 
the full amount of tax owed on or before the      charges if you can show that the reason you 
due date of their return. An extension of         did not pay the full amount by the due date 
time to file is NOT an extension of time to       was due to reasonable cause. 
pay the tax. If you cannot pay the balance 
due by the due date of your return, you must      Make all checks payable to: City of Port Huron. 
sign a payment schedule. We will assess           Write the last four numbers of your Social Security 
penalty and interest charges on all amounts       number or your FEIN on your payment and note 
remaining unpaid after the due date of the        what the payment is for. Mail your signed 
return.                                           application for extension and remittance to: 

When you file an extension request, if you find   City of Port Huron 
that more income tax will be due to the City,     Income Tax Division 
you must pay that amount with this form. We       100 McMorran Boulevard 
will not consider your application a valid        Port Huron, MI 48060 
extension unless you pay the total balance 
due.                                              The City of Port Huron’s Income Tax 
                                                  Administrator requires payment of all amounts 
If you find that no additional tax will be due to due before we will grant an extension under 
the city, you do not need to file this form. A    Sec. 64 of the Uniform City Income Tax 
copy of your federal extension attached to        Ordinance (Public Act 284 of 1964, State of 
your return will be sufficient. Attach a copy of  Michigan, as amended). The Administrator 
all federal and City of Port Huron extensions     deems this extension to meet the 
to your city return when you file it.             requirements for filing a tentative return under 
                                                  Sec. 64 of the Uniform City Income Tax 
Your application for extension must be            Ordinance. 
postmarked on or before the original due date 
of your return.                                   If you have any questions regarding this 
                                                  extension or the City of Port Huron income 
If you do not pay the full amount of tax due      tax, please call(810) 984-9741. You can also 
with your application for extension, we will      visit our office in Room 112 of the Municipal 
assess you interest and penalty on the unpaid     Office Center, 100 McMorran Boulevard, Port 
amount. File your return and pay the balance      Huron, Michigan 48060. 
shown due with the return. Our office will bill 
any interest and penalty charges, based on 
the date you paid the balance. 

We will assess you monthly interest charges 
on any unpaid balance. The monthly interest 
rate is 1/12 of the legally prescribed rate (1% 
above the prime rate, as determined by the 
Michigan Department of Treasury). 

We will also assess a penalty of 1% of the 
balance due per month, for each month the 
payment is late. The total penalty will not 
exceed 25% of the balance due. The 
minimum combined charge for penalty  and