Form 11a - Amended Employer'S Municipal Tax Withholding Statement

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REGIONAL INCOME TAX AGENCY
FORM
11A
Amended Employer's Municipal Tax Withholding Statement
1. Name: _______________________________________________
Fed. ID#: _____________________________
Address #: _______________
Street: _____________________________________________________________
City: ______________________________________________
State: ______
Zip: ______________________
Originally Filed
2.
For the period ______/______/________ to ______/______/________
MM
DD
YYYY
MM
DD
YYYY
Municipality
Workplace
Workplace Tax
Residence Tax
Total Tax
Wages
Withheld
Withheld
Withheld
____________________
$___________________
$______________
$_____________
$_______________
____________________
$___________________
$______________
$_____________
$_______________
____________________
$___________________
$______________
$_____________
$_______________
____________________
$___________________
$______________
$_____________
$_______________
__________
_______
______
_______
Totals
$
$
$
$
Amending To
3.
Municipality
Workplace
Workplace Tax
Residence Tax
Total Tax
Wages
Withheld
Withheld
Withheld
____________________
$___________________
$______________
$_____________
$_______________
____________________
$___________________
$______________
$_____________
$_______________
____________________
$___________________
$______________
$_____________
$_______________
____________________
$___________________
$______________
$_____________
$_______________
__________
_______
______
_______
Totals
$
$
$
$
▲
▲
▲
$_____________
4. Balance Due
$_____________
5. Overpayment
Refund
Credit
(Must distribute in Section 7)

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