City of Portland 

                                        Income Tax Department 

                                                            1.
P-SS-4                                                           FEDERAL EMPLOYER IDENTIFICATION NUMBER 
Employer’s Withholding Registration          
                         
2. Complete Company Name (Include, if applicable, Corp., Inc., L.L.C., etc.) 

3. Business Name, Assumed Name of DBA (If used) 
 
   LEGAL         4A. Enter Number and Street (Address to which correspondence is mailed.)          Business Telephone 
 ADDRESS 
                 City, State, Zip 

   MAILING       4B. Enter Number and Street. (Address to which tax forms are mailed.) 
 ADDRESS 
                 City, State, Zip 
 PHYSICAL        4C  Enter Number and Street. (Address of physical location in the City of Portland.) 
 ADDRESS IN 
 PORTLAND        City, State, Zip 
Complete all information for each owner, partner, member or corporate officer.  Attach a separate list if necessary. 
5A.  Name (Last, First, Middle Initial)                     Home Telephone 

Business Title                                              Date of Birth 

Residence Address (Number, Street)                          Social Security Number 

City, State, Zip                                            Driver License/Michigan Identification 

5B. Name(Last, First, Middle Initial)                       Home Telephone  

Business Title                                              Date of Birth 

Residence Address (Number, Street)                          Social Security Number 

City, State, Zip                                            Driver License/Michigan Identification 

COMPLETE THIS REGISTRATION IF REQUIRED TO WITHHOLD OR VOLUNTARILY WITHHOLDING AND: 
   1)  Started a new business; or 
   2)  Reinstated an old business; or 
   3)  Purchased an ongoing business; or 
   4)  Started doing business in Portland; or 
   5)  Changed the type of business ownership (eg: from sole proprietorship to partnership, incorporating a sole 
       proprietorship or partnership) 
EMPLOYERS REQUIRED TO REGISTER AND WITHHOLD: 
   1) Employers having a location in the City of Portland; or 
   2) Employers doing business in the City of Portland even though they have no location in the City. 
WITHHOLD TAX FROM WAGES PAID TO THE FOLLOWING EMPLOYEES: 
   1)  All residents of the City of Portland whether or not they work in the city; 
   2) All non-residents of the City of Portland who work in Portland (withhold only on wages earned in Portland) 
For further information refer to the Income Tax Ordinance or call the Income Tax Department at (517) 647-2941. 
Tax Forms are also on our website, www.portland-michigan.org. 
                                         

  6.  TYPE OF BUSINESS OWNERSHIP  (CHECK ONE ONLY) 
   
       
  (1) Individual                                                                       
       
  (2) Partnership 
       
  Registered Partnership Agreement Date:________ 
       
  Limited Partnership 
          Identify all general partners above. 
       
  (3) Limited Liability Co. 
       
  (4) Corporation 
       
  Sub Chapter S 
       
  Professional 
       
  (5) Non-Profit Corporation 
       
  (6) Government 
       
  (7) Trust or Estate (Fiduciary) 
       
  (8) Other (Explain)______________________________________________ 
    
  State of Incorporation                                                                         Michigan Corporation Number 

  7. DATE YOU FIRST PAID WAGES SUBJECT TO PORTLAND                                               CONTACT PERSON FOR WITHHOLDING TAX 
  WITHHOLDING                                                                                    QUESTIONS (NAME AND PHONE) 
  NUMBER OF EMPLOYEES SUBJECT TO PORTLAND WITHHOLDING 

  8.  REASON FOR REGISTRATION 
       
   Started a new business on ____________________ 
       
  Incorporated an existing business 
       
  Purchased a going business.  Complete item 9 below. 
       
  Reinstated an old business.  Old account no.___________________ 
       
  Stated doing business in Portland 
       
  Other (explain)  _____________________________________________ 
           
  9.  NAME OF PREVIOUS OWNER OF CORPORATION 
   
  WILL THE PREVIOUS OWNER CONTINUE TO HAVE EMPLOYEES SUBJET TO THE PORTLAND INCOME TAX WITHHOLDING?    
              
  YES 
              
  NO 
  10.  DO YOU CLOSE YOUR BOOKS FOR TAX PURPOSES (FOR THE YEAR) ON DECEMBER 31ST? 

  11. SIGNATURE (of the officer or owner who controls or is responsible for                      TITLE 
  filing Returns, and making payments of Portland taxes.) 

  TYPE OR PRINT NAME                                                                             DATE 

  SIGNATURE                                                                                      TITLE 

  TYPE OR PRINT NAME                                                                             DATE 

                                                                                                        Revised 10/2012 
P-SS-4 
Questions on this application?  Call the Income Tax Department at (517) 647-2941 
 
Mail To:        City of Portland 
                Income Tax Department 
                259 Kent Street 
                Portland, MI  48875