City of Lapeer 
                                                Income Tax Department 
 
L-SS-4                                                                   1.  Federal Employer Identification Number 
Employer’s Withholding Registration 
2. Complete Company Name (Include, if applicable. Corp., Inc., LLC. etc. 

3. Business Name, Assumed Name of DBA (If used) 

LEGAL            4a. Enter Number and Street (include apartment or suite number after street name)       Business Telephone 
ADDRESS 
                 City, State, Zip 

MAILING          4B. Enter Number and Street (include apartment or suite number after street name) 
ADDRESS 
                 City, State, Zip 

PHYSICAL         4C. Enter Number and Street (include apartment or suite number after street name) 
ADDRESS IN 
LAPEER           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/State Identification Number 

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/State Identification Number 

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 Lapeer; 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 Lapeer; or 
2)  Employers doing business in the City of Lapeer even though you have no location in the City. 
WITHHOLD TAX FROM WAGES PAID TO THE FOLLOWING EMPLOYEES: 
1)  All residents of the City of Lapeer whether or not they work in the city: 
2)  All non-residents of the City of Lapeer who work in Lapeer (withhold only on wages earned in Lapeer) 
For further information refer to the Income Tax Ordinance or call the Income Tax Department at 810-667-7155. Tax Forms are also on 
our website, www.ci.lapeer.mi.us     

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 Company – Identify all members above. 
______(4)  Corporation 
                   _______Sub Chapter S   
______(5)  Non-Profit Corporation 
______(6)  Government 
______(7)  Trust or Estate (Fiduciary) 
______(8)  Other (Explain)__________________________________________________________________ 

7. State of Incorporation               State Corporation Number       Date you first paid wages subject to Lapeer Withholding 

Contact Person for Withholding Tax (required)                          Number of Employees Subject to Lapeer Withholding 

Contact Person Phone Number (required)                                 Contact Person E-Mail (required) 

8. REASON FOR REGISTRATION 
_______(1) Started a new business on ______________ 
_______(2)  Incorporated an existing business.  Date:_________________ 
_______(3)  Purchased a going business. Complete item 9 below. 
_______(4)  Reinstated an old business.  Old Account No. ___________________  Date:__________________ 
_______(5)  Started doing business in Lapeer.  Date:_______________________ 
_______(6)  Other (explain)___________________________________________________________________ 

9. NAME OF PREVIOUS OWNER OF CORPORATION 
WILL THE PREVIOUS OWNER CONTINUE TO HAVE EMPLOYEES SUBJECT TO LAPEER INCOME TAX WITHHOLDING? 
________YES             ___________NO 
 
                                                                                    ST
10. ENTER FISCAL YEAR USED IF NOT YEAR ENDING ON DECEMBER 31 . 

Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it 
is  true, correct, and complete. 
1a. Signature (owner, member or officer who controls or is responsible for filing                 TITLE 
withholding tax returns and paying the income tax withheld)        

TYPE OR PRINT NAME                                                                                       DATE 
                                                                                                          
L-SS-4 
If you have questions on this application call the Lapeer City Income Tax Department at 810-667-7155 
 
Fax to 810-667-7157 or E-mail: income tax@ci.lapeer.mi.us or 
   
Mail to: City of Lapeer Income Tax Department, 576 Liberty Park, Lapeer MI  48446 
  
 Information collected on this form is confidential pursuant to MCL 141.674(1), Michigan Uniform City Income Tax Ordinance; 
 Sec.74(1). Information gained by the administrator, city treasurer or any other city official, agent or employee as a result of a return, 
 investigation, hearing or verification required or authorized by this ordinance is confidential, except for official purposes in 
 connection with the administration of the ordinance and except in accordance with a proper judicial order.