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

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RITA
PHONE: (440) 526-0900 CLEVELAND LOCAL
FAX: (440) 717-9448
TDD: (440) 526-5332
(614) 538-0512 COLUMBUS LOCAL TOLL FREE: 1-800-860-RITA
WEB ADDRESS:
PO Box 94736
Cleveland, OH 44101-4736
FORM
SECTION
11
A
1. TOTAL WAGES SUBJECT
,
,
.
TO WORKPLACE TAX
$
FORM 11A
Section B must be completed. Section A must equal Section B.
2. AMOUNT OF WORKPLACE
Negative amounts are not acceptable.
,
,
.
TAX WITHHELD
$
REGIONAL INCOME TAX AGENCY EMPLOYER’S MUNICIPAL TAX WITHHOLDING STATEMENT
FOR THE PERIOD
3. AMOUNT OF RESIDENCE
,
,
.
TAX WITHHELD
$
TO
DUE ON OR BEFORE
,
,
.
4. AMOUNT DUE AND PAID
$
MAKE CHECK PAYABLE TO: RITA
FED. ID #:
I HAVE EXAMINED THIS RETURN. TO THE BEST OF MY KNOWLEDGE IT IS CORRECT.
NAME:
SIGNATURE
ADDRESS #:
SUITE:
TITLE ___________________________
DATE ______________________________
STREET NAME:
—
(
)
PHONE NUMBER
CITY:
–
STATE:
ZIP:
SECTION
B
MUNICIPALITY
WORKPLACE WAGES
WORKPLACE
WORKPLACE
RESIDENCE TAX
TAX RATE
TAX WITHHELD
WITHHELD
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