RESIDENT INCOME TAX FORM - 1040EZ

This form is only for a person that was a resident of Grand Rapids for all of the year with income only derived from wages, interest or dividends with none of the income being excludable from the Grand Rapids Income tax return.

You cannot use this form if you received alimony payments, had Grand Rapids business income (Schedule C), sold or exchanged property (Schedule D or 4797), had taxable IRA distributions, taxable pension/annuity distributions, supplemental income (Schedule E or F), miscellaneous income, exclusions, or adjustments, or Credits paid by a Corporation.

*Due to the high volume of returns it can take 2-4 weeks to process your payment or refund. Once you

receive your confirmation we have received your return. If there are any issues you will receive a phone call,

email, or letter in the mail.

What Tax Year are you filing for? *

Taxpayer Social Security number *

Taxpayer Name *

Date of Birth (MM/DD/YYYY) *

Taxpayer Address *

City *

State *

Zip Code *

Phone Number (no dashes or spaces) *

Email Address *

Are you filing jointly? *

Yes

No

Spouses' Social Security number

Spouse Name

Income Information

1. Total Wages, Salaries, and tips. Total from Box 1 of all your W-2 forms. *

2. Interest income- Report all taxable income *

3. Dividend Income – Report all dividend income *

4. Add Lines 1,2, and 3. This is your total Grand Rapids Income.

0

5. Number of Exemptions *

6. Exemption total

0

7. Total Income subject to tax (subtract Line 6 from Line 4)

0

8. Total Tax Due

0

First and Second page of your federal return

Payments and Credits

9. Total Grand Rapids tax withheld by employers (Attach W-2 forms showing Grand Rapids tax withheld) *

Upload any W-2's. (If W-2 is not uploaded refund may be delayed.)

Do you have more than one W-2?

W-2 upload #2

W-2 upload #3

W-2 upload #4

W-2 upload #5

10. Estimated Payments made to Grand Rapids - NOT WITHHOLDING Estimated payments are payments made individually to the City and are required if you owe over $100 a year. *

11. Credit for Income Tax paid to another Michigan City (upload the 1st page of each tax return) *

Copy of 1st page of other City's return

12. Total Credits and Payments

0

Refund or Tax Due

13. Tax Due or Refund (refunds will be a negative number)

0

14. Is #13 a positive number? *

Yes

No

Payment

Pay by Check - Mail

Pay by Credit Card - 2.5 % FEE

Pay by E-check - no fee

Please send Check to: Grand Rapids Income Tax

Payment by E- Check - Routing number

Account number

Type of Account

Name on Card

Credit Card Type

Credit Card Number

Expiration Date (mm/yy)

CVV

Refund

Credit Forward	Donation
Refund via EFT or Paper Check

Refund Type

Credit Forward

Donation

American Flags

Children's Fund

Donation Amount- Children's fund

Donation Amount- Veteran's fund

EFT - Refund - Routing number

Account number

Type of Account

Paper Check Refund

Acknowledgement and Agreement

Under the penalty of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. If prepared by a person other than taxpayer, the preparer's declaration is based on all information of which preparer has any knowledge.

Taxpayer Name *

Date *

Spouse Name

Date

Please print this page before you submit (ctrl P). Once you have submitted this form you will receive a reference number. You cannot return to print this form later. We have received your form once you receive a reference

number. It can take 2-4 weeks to process a check or refund.

Thank you.