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FORM
11A
1. Name: ______________________________________________
Fed. ID#: ____________________________
Address #: ______________
Street: ____________________________________________________________
City: _____________________________________________
State: _____
Zip: _____________________
2. Originally Filed
For the period ______/______/________ to ______/______/________
MM DD YYYY MM DD YYYY
Municipality Workplace Workplace Tax Residence Tax Total Tax
Wages Withheld Withheld Withheld
__________________
$__________________
$______________ $_____________ $_______________
__________________
$__________________
$______________ $_____________ $_______________
__________________
$__________________
$______________ $_____________ $_______________
__________________
$__________________
$______________ $_____________ $_______________
Total
_________
______
______
_______
3. Adjusting To
Municipality Workplace Workplace Tax Residence Tax Total Tax
Wages Withheld Withheld Withheld
__________________
$__________________
$______________ $_____________ $_______________
__________________
$__________________
$______________ $_____________ $_______________
__________________
$__________________
$______________ $_____________ $_______________
__________________
$__________________
$______________ $_____________ $_______________
Total
_________
______
______
_______
4. Balance Due $_____________
5. Overpayment $_____________
Refund
Credi
(Must distribute in Section 7)
Regional Income Tax Agency
Adjusted Employer's Municipal Tax
Withholding Statement