Form 10a - Regional Income Tax Agency Application For Municipal Income Tax Refund
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3Contact us toll free:
Cleveland
800.860.7482
10A
Columbus
866.721.7482
Regional Income Tax Agency
Youngstown
866.750.7482
Application for Municipal Income Tax Refund
TDD
440.526.5332
Your first name and middle initial
Last name
Your social security number
Tax year of claim
Current home address (number and street)
Apt #
City, state, and ZIP code
Daytime phone number
Evening phone number
Reason for Claim
Check the box below that applies.
• A separate 10a is required: If you have multiple W-2 forms or for each municipality from which a refund is requested.
• No refunds will be issued without the proper documentation indicated by reason for claim.
1.
Age Exemption. Date of Birth:
. Attach a copy of your W-2 Form and proof of birthdate (birth
certificate, driver’s license, etc). If you were under 18 for only part of the year, you must either: 1) have your employer
sign the completed Employer Certification on page 2; or 2) attach a copy of your pay stub for the pay period in which
your birthday fell.
Exceptions to the 18 years of age or older exemption exist. For more information, visit
, select the RITA municipality in which you worked and review the Special Notes section that relates to
the appropriate tax year.
2.
Un-reimbursed business expenses. Attach a copy of your W-2 Form, the federal Schedule A and federal Form 2106
filed with your federal 1040. Employer does NOT need to complete the Employer Certification on page 2.
3.
Days worked outside of municipality for which the employer withheld tax. Attach a copy of your W-2 Form, a completed
Log of Days Out Worksheet on page 3, and a completed Calculation for Days Worked Out of RITA on page 3. In addition,
your employer must complete and sign the Employer Certification Parts 1 and 2 on page 2.
Employer withheld at a rate higher than the municipality’s tax rate. Attach a copy of your W-2 Form. Your
4.
employer must complete and sign the Employer Certification Parts 1 and 2 on page 2.
5.
Employer withheld too much (over-withheld) resident municipality tax. Attach a copy of your W-2 Form. Your
employer must sign the Employer Certification Part 2 on page 2.
Withheld by mistake for the municipality of
when I actually worked in the municipality of
.
6.
Attach a copy of your W-2 Form. Your employer must sign the Employer Certification Part 2 on page 2. Indicate the
address where you actually worked.
Work Location Street Address
City
State
Zip
Over-the-road truck driver. The wages of an interstate trucker regularly assigned to drive in more than one state are
7.
only taxable by the trucker’s municipality of residence. Truck drivers assigned to drive in multiple Ohio municipalities only
may be eligible to receive a 90% refund from their principal place of work. Your employer must complete and sign the
Employer Certification Part 2 on page 2.
Military Spouse Residency Relief Act. Attach copies of W-2 Form, Form DD 2058, valid military spouse ID card and
8.
service member’s most recent LES.
Other (Indicate Reason). Attach W-2 Form and other applicable documentation. Your employer must complete and
9.
sign the Employer Certification Parts 1 and/or 2 on page 2.
10.
Refund of overpayment on account If you have already filed Form 37 or are not required to file. Employer
certification is not required.
Claim
Employer Name
1 Employer Federal ID #
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2 RITA Municipality for which tax was withheld (from W-2, Box 20).
RITA cannot refund tax withheld to a Non-RITA municipality
2
3
Amount of income not taxable. For reason 2 enter your 2106 expenses less the 2% limitation. Enter -0-
3
for reasons 4 and 5. For all other reasons enter the amount of wages you are claiming are not taxable
4 Amount of over withholding claimed
4
5 Amount of over withholding you want applied as a payment to your individual or joint
account instead of being refunded to you. Enter -0- if you want all of your refund sent to you
5
SSN of account to be credited
Provide the social security number of the account to which you want
the amount on line 5 to be credited
6
Net amount to be refunded. Subtract line 5 from line 4. Amounts $10 or less will not be refunded.
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