GR-4868                                                                 GRAND RAPIDS                                               202 2RET REX 
                                              APPLICATION FOR AUTOMATIC EXTENSION OF TIME 
                                                         TO FILE AN INDIVIDUAL INCOME TAX RETURN 

Taxpayer Name: 
Social Security No: 
File on or Before:                         5/01/2023, due date of 202 2return. * 
Payment:                                   $  

Payment Method:                            • Make payment by check or money order payable to "City of Grand Rapids." DO NOT SEND CASH.
                                           • Write your Soc. Sec. No., daytime phone number and "2023 GR-4868" on check or money order.
                                           • To pay by credit card or direct debit, see income tax website of the City of Grand Rapids.

Address for Payment:                       Grand Rapids Income  Tax Department 
                                           PO Box 108 
                                           Grand Rapids, MI  49501-0108 

Instructions:                              • An extension to file does not extend the due date to pay tax. Tax paid late will be assessed late fees.
                                           • Line 1: Enter the total tax liability you expect to report on your 2023 Form GR-1040, page 1, line 23.
                                           • Line 2: Enter the total payments that you expect to report on your 2023 Form GR-1040, page 2, line 4,
                                           not including the extension payment reported on line 3 of this form.
                                           • Filing date: The income tax ordinance limits an extension to SIX months from the original due date.

Related Information:                       • Federal extension: Filing a federal extension (Form 4868) with the Internal Revenue Service does not
                                           grant an extension of time to file a Grand Rapids income tax return. 
                                           • Persons living outside the United States: Where the Internal Revenue Code grants an automatic two- 
                                           month extension to persons living outside the U.S., an automatic two-month extension will be granted.

Payment:                                   • An extension is automatically granted upon payment of the balance due (line 3); failure to  pay the balance
                                           due invalidates the extension request; an extension filed without a payment will not be accepted.
                                           • Interest and penalty will be assessed on taxes paid late even if an extension of time to file is granted.
                                           • Penalty may be waived by the Income Tax Administrator if the tax paid by the original due date is not
                                           understated by more than 5% of tax or the taxpayer can show that the failure to pay on time was due to
                                           reasonable cause.
* Due Date                                 • If the due date falls on a Saturday, Sunday or holiday, the due date is the next business day.

Taxpayer Records:                          Amount Paid:                    Check Number:                              Date Mailed: 
                                                                                                                                           Revised: 04/21/2015 
       KEEP TOP PORTION FOR YOUR RECORDS.  SEND BOTTOM PORTION WITH YOUR   PAYMENT 
                                                                        v  DETACH HERE v 
GR-4868                                                                 GRAND RAPIDS                                               202 2RET REX 
           APPLICATION FOR AUTOMATIC EXTENSION OF TIME TO FILE AN INDIVIDUAL INCOME TAX   RETURN 
                                                                        Mail To:  Grand Rapids Income Tax Department 
                                                                        PO Box 108 
NACTP #                                                                 Grand Rapids, MI 49501-0108 
EFIN #                                                                                                                                 Revised: 04/21/2015 
Taxpayer's first name, initial, last  name                              Taxpayer's SSN 

If joint return spouse's first name, initial, last  name                If joint payment, spouse's SSN 

Present home address (Number  and street)                      Apt. no. Payment voucher 2D barcode 

Address line 2 (P.O. Box address for mailing use  only) 

City, town or post office                                State Zip code 
                                                                        1. Estimate of total tax liability for 2023                                   .00 
Foreign country name, province/county, postal  code                     2. Total 2023 payments and credits                                            .00 
                                                                        3. Balance due (Line 1 less line 2)                                           .00