Form 11 - Regional Income Tax Agency Employer'S Municipal Tax Withholding Statement

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REGIONAL INCOME TAX AGENCY EMPLOYER’S MUNICIPAL TAX WITHHOLDING STATEMENT
FORM
11
SECTION
A
,
,
1. TOTAL WAGES SUBJECT
FOR THE PERIOD
.
$
TO WORKPLACE TAX
11LF05A
,
,
2. TOTAL AMOUNT OF
TO
.
$
WORKPLACE TAX WITHHELD
DUE ON OR BEFORE
,
,
3. TOTAL AMOUNT OF
.
$
RESIDENCE TAX WITHHELD
FED. ID #:
,
,
.
$
4. TOTAL AMOUNT DUE AND PAID
NAME:
MAKE CHECK PAYABLE TO: R.I.T.A.
I HAVE EXAMINED THIS RETURN, AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT.
ADDRESS #:
SUITE:
SIGNATURE
STREET NAME:
PRINT NAME
CITY:
DATE
TITLE
STATE:
ZIP:
PHONE NUMBER
SECTION
SECTION B MusT BE COMPLETED. SECTION A MusT EqUAL SECTION B.
CHECK HERE IF YOU HAVE ANY CHANGES TO YOUR
B
NEGATIVE AMOUNTS ARE NOT ACCEPTABLE.
DISTRIBUTION AND COMPLETE SECTION B ON THIS FORM.
MUNICIPALITY
WORKPLACE WAGES
WORKPLACE
WORKPLACE
RESIDENCE TAX
TAX RATE
TAX WITHHELD
WITHHELD
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REGIONAL INCOME TAX AGENCY
YOUNGSTOWN TOLL FREE: (866) 750-RITA (7482)
CLEVELAND LOCAL: (440) 526-0900
COLUMBUS TOLL FREE: (866) 721-RITA (7482)
P.O. Box 94736 Cleveland, Ohio 44101-4736
TOLL FREE: (800) 860-RITA (7482)
TDD: (440) 526-5332
FAX: (440) 717-9448

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