CITY OF PORT HURON                                                                                                             TAX YEAR being amended: 
PH-1040X 
Revised 1 /20 2                       AMENDED INDIVIDUAL INCOME TAX RETURN 
Your first name and initial                                        Last name                                                            Your social security number 

If a joint return, spouse's first name and initial                 Last name                                                            Spouse's social security number 

Home address (number and street or PO Box)                                                                         Apartment number     Is this the same name and address 
                                                                                                                                        as your original return? 
City, town or post office, state and ZIP code 
                                                                                                                                                                     Yes  No 

RESIDENCY STATUS            Resident                            Nonresident                 Partial Resident       If a PARTIAL RESIDENT, enter the dates you lived in the city: 
On original return                                                                                                 FROM:                                             TO: 
On this return                                                                                                     FROM:                                             TO:  

FILING STATUS                         Single                    Married filing joint return Married filing separate return 
On original return                                                                                                         Note: you cannot change from joint to separate 
                                                                                                                           returns after the due date for filing has passed 
On this return 

                                                                                                                   A.                   B.                                C. 
                                                                                                                   On Original Return Net Change                          Correct Amount 
                                                                                                                                      Increase  or 
AMOUNT OF TAX                                                                                                                         (Decrease) 
1. Total income . . . . . . . . . . . . . . . . . . . . . . . .                                                  1 
2. Exemption credit. If changing, fill out part I on the back . . . . . .  .                                     2 
3. Taxable income. Subtract line 2 from line 1. If less than zero, enter -0-                                     3 
4. Tax. Residents 1% (.01), nonresidents ½ of 1% (.005), or Schedule L                                           4 
PAYMENTS 
5. Total Port Huron tax withheld . . . . . . . . . . . . . . . . .                                               5 
6. Estimated tax payments and amounts carried forward from last year                                             6 
7.   Other credits .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   . 7 
8. Amount paid with your original return plus any additional tax paid after it was filed . . . . . . . . . . . . .  .                                                8 
9. Total payments and credits. Add lines 5 through 8 in column C . . . . . . . . . . . . . . . . . . . . .  .                                                        9 
REFUND OR BALANCE DUE 
10. Refund, if any, shown on your original return  .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   . 10 
11. Subtract line 10 from line 9, this is the net tax you paid to the city  .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .        11 
12. If line 4 is more than line 11, subtract line 11 from line 4.  This is your tax due .............................. PAY BALANCE DUE                               12 
13. If line 11 is more than line 4, subtract line 4 from line 11.  This is the amount you overpaid ................ OVERPAYMENT                                      13 
                                                                   Be sure to complete the back of the return 
I declare, under penalty of perjury, that the information in this return and attachments is true and               I declare under penalty of perjury, that this return is based on all 
complete to the best of my knowledge.                                                                              information of which I have knowledge. 
Your signature                                                                              Date 
                                                                                                                   Preparer's name, address and ID number 
X 
Spouse's signature - if a joint return BOTH MUST SIGN                                       Date 
X 
                                                                                                                   Preparer's signature                                   Date  
Make checks payable to:  City of Port Huron                     Mail to: Income Tax Division 
If paying in person, pay at the City Treasurer's Office.           100 McMorran Blvd. 
To pay online, go to www.porthuron.org.                            Port Huron, MI  48060                           X 

PART I - Exemptions Complete this section if you are changing the number of exemptions claimed. Show the CORRECT information below.
Check all boxes that apply: 
                       extra exemptions if:                                             extra exemptions if: 
           65 or older blind     deaf       disabled                        65 or older blind deaf           disabled 
You:                                                 Spouse: 

Dependents 
First name             Last name                     Social security number Relationship to you              Number of exemptions claimed 
                                                                                                             on your original return: 

                                                                                                             Number of exemptions claimed 
                                                                                                             on this return: 

                                                                                                             Difference: 

PART II - Explanation of Changes Explain why this return is being amended below.