CLEAR FORM
                                                 Application for Auto Extension of Time                               SF- 4868 
                                                 To File Springfield Income Tax Return 
                                                                                              PRINT FORM
                                                                                                                    Year 

        First name, initial, spouse's name and initial      Last Name                                        Social Security number 
PLEASE 
TYPE OR Number and Street                                                                             Spouse's Social Security number 
PRINT
        City or Town                             State                         Zip Code                      Employer ID number 

EXTENSION IS                   INDIVIDUAL                   CORPORATION                  PARTNERSHIP           ESTATE 
REQUESTED FOR:                                   CALENDAR YEAR FILER                     FISCAL YEAR FILER 

                 Prepare this form in duplicate. File the original with the Springfield Income Tax Department on or before the due date for 
INSTRUCTIONS:    filing your return (if you wish to have an approved copy, you must enclose a stamped pre-addressed envelope.) Attach 
                 the duplicate to your Springfield Income Tax Return when filed. 

INDIVIDUAL       When form SF-4868 is timely filed, an automatic extension will be granted for individual returns until August 30th of the 
RETURNS          year the return is due. The tentative tax must be paid with this application for extension. 

                 When an extension of greater than four months is requested, the tax tentatively determined to be due must be paid by 
                 the last day of the fourth month. The uniform City Income Tax Ordinance limits the extension of time for filing annual 
CORPORATIONS 
                 returns to six months from the due date. 
PARTNERSHIPS 
ESTATES 
                 A      month extension of time for filing until is hereby requested in which to file the Springfield Tax Return as indicated 
                 above for the calendar year                or the fiscal year beginning        and ending          . 

TENTATIVE TAX COMPUTATION: 

              1  Tentative City of Springfield Income Tax                                                    $ 
              2  Less: 
                 a. City Income Tax Withheld                               $ 
                 b. Estimated Tax Paid to Springfield                      $ 
                 c. Other Credits                                          $ 
                 d. Total Credits (add lines a, b and c)                                                     $ 

              3  Balance Due (line 1 less line 2d)                                                           $ 
                                                                               ANY BALANCE DUE MUST BE PAID WITH THIS APPLICATION 

SIGNATURE AND VERIFICATION: 
        Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements and to 
        the best of my knowledge and belief, it is true, correct, and complete; if prepared by someone other than the taxpayer, I am 
        authorized to prepare this form. 

        Signature of taxpayer: 
                                                                                                Date 

        Signature of spouse: 
                                                 (if filing jointly, both must sign)            Date 

        Signature of preparer: 
                                                                                                Date 
              MAIL TO: SPRINGFIELD INCOME TAX DEPARTMENT, 601 AVENUE A, SPRINGFIELD, MI 49037-7774 
                                             (Make checks payable to: City of Springfield) 
        Your request for an Extension is:                   APPROVED                     DENIED 

             By: 
                 Finance Director                                                        Date