City of Big Rapids 
                                                      AMENDED 
                                                Income Tax Form 
   **** A COPY OF THE ORIGINAL MUST ACCOMPANY THIS AMENDED RETURN**** 
 Year Being Amended:                                  Type of Return: 
                                                               
                                                              BR 1040                          BR 1120                           BR 1065 
 Your First Name and Initial                          Last Name                                                         Your Social Security Number 

 If Joint, Spouse’s First Name and Initial            Last Name                                                         Your Spouse’s Social Security Number 

 Address (Number and Street) 

 City, State, and Zip 

 Reason for Amendment (including calculations) 
  
  1. INCOME ................................................................................................. 1. 
  2. ADDITIONS TO INCOME ...................................................................... 2. 
  3. SUBTRACTIONS FROM INCOME  ....................................................... 3. 
  4. IRA DEDUCTIONS ................................................................................ 4. 
  5. ADJUSTED INCOME (add line 1 & 2, Subtract 3 & 4) ........................................ 5. 
  6. EXEMPTIONS ........................................................................................ 6. 
  7. TAXABLE INCOME (Line 5 less line 6)  ......................................................... 7. 
  8. TAX ........................................................................................................ 8. 
 
   Original Tax Paid…………………………………                               
   Original Tax Withheld……………………………                             
   Original Tax Refunded…………………………..                            
   Additional Amount to be Refunded…………….                       
   Additional Amount Owed………………………..                            
    Interest - .0001411 per day…………………                          
    Penalty - 1% per month not to exceed 25%   
                      of tax owed or a combined minimum of 
                      $2.00…………………………………….. 
   TOTAL TAX DUE………………………………...                                 
   **** A COPY OF THE ORIGINAL MUST ACCOMPANY THIS AMENDED RETURN**** 
  I declare, under penalty of perjury, that the information on this return and attachments is true and complete. 
   I authorize the City to discuss my           DO NOT discuss my                                               I declare, under penalty of perjury, that this return 
   claim and attachments with my preparer       claim with my preparer.                                         is based on all information of which I have knowledge. 
    
                                                                                                                PREPARER’S SIGNATURE AND ADDRESS                      
  Filer’s Signature                                   Date                
                      Birthdate                                           
                                                                          
  Spouse’s Signature                                  Date                                                       
                                                                                                                Phone (         )                      - 
                      Birthdate