PLEASE TYPE                    City of Muskegon                                       PLEASE TYPE
                OR PRINT                                                                              OR PRINT
                                               INCOME TAX DEPARTMENT

M-SS-4                                                                    1. FEDERAL EMPLOYER IDENTIFICATION NUMBER
Employer's Withholding Registration
2. COMPLETE COMPANY NAME (Include, if applicable, Corp., Inc., L.C., etc.)

3. BUSINESS NAME, ASSUMED NAME OR DBA (if used)

        4A. THIS ADDRESS IS WHERE ALL LEGAL CONTACT SHOULD BE MADE.  ENTER NUMBER AND STREET.   BUSINESS TELEPHONE
LEGAL
ADDRESS CITY, STATE, ZIP

        4B. THIS ADDRESS IS WHERE MUSKEGON WILL SEND ALL TAX FORMS.  ENTER NUMBER AND STREET.
MAILING
ADDRESS CITY, STATE, ZIP

        4C. THIS ADDRESS IS THE ACTUAL LOCATION OF THE BUSINESS IN MUSKEGON.  ENTER NUMBER AND STREET.
PHYSICAL
ADDRESS
IN      CITY, STATE, ZIP
MUSKEGON

Complete all information for each owner, partner, member or corporate officer.  Attach a separate list if necessary.
5A. NAME (Last, First, Middle, Jr./Sr./III)                                                     HOME TELEPHONE

BUSINESS TITLE                                                                                  DATE OF BIRTH

RESIDENCE ADDRESS (Number, Street)                                                              SOCIAL SECURITY NUMBER

CITY, STATE, ZIP                                                                                DRIVER LICENSE/MICHIGAN IDENTIFICATION

5B. NAME (Last, First, Middle, Jr./Sr./III)                                                     HOME TELEPHONE

BUSINESS TITLE                                                                                  DATE OF BIRTH

RESIDENCE ADDRESS (Number, Street)                                                              SOCIAL SECURITY NUMBER

CITY, STATE, ZIP                                                                                DRIVER LICENSE/MICHIGAN IDENTIFICATION

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 a going business; or
4)  Started doing business in Muskegon; or
5)  Changed the type of business ownership (eg: from sole proprietorship to partnership or incorporating a sole proprietorship or partnership).
FILL OUT THIS REGISTRATION FORM COMPLETELY.
•  The SIC Code Number requested in Section 6 is the Standard Industrial Classification Group Number.
•  Check to see that necessary signature(s) is/are affixed in Section 11.
•  Mail the completed registration to the address on reverse side.
EMPLOYERS REQUIRED TO REGISTER AND WITHHOLD
1)  Employers having a location in the City of Muskegon; or
2)  Employers doing business in the City of Muskegon even though having no location in the City.
EMPLOYEES TO WITHHOLD FROM
1)  All residents of the City of Muskegon whether or not they work inside the city;
2)  All nonresidents of the City of Muskegon who work in Muskegon (withhold only on wages earned in Muskegon).
For further information refer to the Income Tax Ordinance, the Withholding Tax Guide or call the Income Tax Department at (231) 724-6770.
You will receive your pre-identified withholding tax forms in two to three weeks after your registration is processed.  If you need other City of
Muskegon tax forms or large quantities of this registration form, please call (231) 724-6770.

6. TYPE OF BUSINESS OWNERSHIP (check one only)
   (1) Individual                                       (2) Limited Liability Co.                      (3) Non-MI Corporation
   (2) Partnership                                                      Domestic (Michigan)            (1) Subchapter S
        (2) Registered Partnership                                      Professional                   (4) Non-Profit Corporation
        Agreement Date:                                                 Foreign (Non-Michigan)         (5) Government
        (2) Limited Partnership                         (3) Michigan Corporation                       (6) Trust or Estate (Fiduciary)
        Identify all general partners above.                            (1) Subchapter S               (9) Other (Explain)
                                                                        (2) Professional
SIC CODE NUMBER                                     STATE OF INCORPORATION                             MICHIGAN CORPORATION NUMBER

7. DATE YOU FIRST PAID WAGES SUBJECT TO MUSKEGON WITHHOLDING                                    CONTACT PERSON FOR WITHHOLDING TAX QUESTIONS
                                                                                                (Name and Phone)
NUMBER OF EMPLOYEES SUBJECT TO MUSKEGON WITHHOLDING

8. REASON FOR REGISTRATION
     Started a new business on                                                          Reinstating an old business.  Old account no.
     Incorporated an existing business                                                  Started doing business in Muskegon
     Purchased a going business.  Complete Item 9 below.                                Other (explain)

9. NAME OF PREVIOUS OWNER OR CORPORATION

WILL THE PREVIOUS OWNER CONTINUE TO HAVE EMPLOYEES SUBJECT TO MUSKEGON WITHHOLDING TAX?

10. DO YOU CLOSE YOUR BOOKS FOR TAX PURPOSES (FOR THE YEAR) ON DECEMBER 31?
     YES      NO  If no, give closing month and day:
11. SIGNATURE OF OWNER(S) – 2 PARTNERS, 2 CORPORATE OFFICERS OR AUTHORIZED REPRESENTATIVE

SIGNATURE (of officer or owner who controls or is responsible for filing                   TITLE
returns and making payment of Muskegon taxes.)

TYPE OR PRINT NAME                                                                         DATE
        PLEASE PROVIDE THE EMAIL ADDRESS OF THE PRIMARY CONTACT PERSON
SIGNATURE                                                                                  TITLE

TYPE OR PRINT NAME                                                                         DATE
      EMAIL ADDRESS_________________________________________________________________________________

M-SS-4
Questions on this application?  Call the Income Tax Department at (231) 724-6770.

MAIL     CITY OF MUSKEGON
TO:      INCOME TAX DEPARTMENT
         P.O. BOX 29
         MUSKEGON, MI 49443-0029