Fillable FORM REGIONAL INCOME TAX AGENCY: 11A Adjusted Employer's (RITA Ohio)

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FORM REGIONAL INCOME TAX AGENCY: 11A Adjusted Employer's (RITA Ohio)

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FORM REGIONAL INCOME TAX AGENCY
11A Adjusted Employer's Municipal Tax Withholding Statement
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
s
$
_________
_
$
______
_
$
______
$
_______
3. Adjusting To
Municipality Workplace Workplace Tax Residence Tax Total Tax
Wages Withheld Withheld Withheld
_
__________________
_
$__________________
$______________ $_____________ $_______________
_
__________________
_
$__________________
$______________ $_____________ $_______________
_
__________________
_
$__________________
$______________ $_____________ $_______________
_
__________________
_
$__________________
$______________ $_____________ $_______________
Total
s
$
_________
_
$
______
_
$
______
$
_______
▲
▲
▲
4. Balance Due $_____________
5. Overpayment $_____________
Refund
Credi
t
(Must distribute in Section 7)
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
6. Reason for Adjusting (Must Be Provided)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
7.
Distribution of Overpaymen
t
(From Section 5)
Municipality
Amoun
t
Distribute Credit to
Tax Period
_
__________________
_
$__________________ ______/______/_________
MM DD YYYY
_
__________________
_
$__________________ ______/______/_________
MM DD YYYY
_
__________________
_
$__________________ ______/______/_________
MM DD YYYY
_
__________________
_
$__________________ ______/______/_________
MM DD YYYY
_
__________________
_
$__________________ ______/______/_________
MM DD YYYY
_
__________________
_
$__________________ ______/______/_________
MM DD YYYY
_
__________________
_
$__________________ ______/______/_________
MM DD YYYY
_
__________________
_
$__________________ ______/______/_________
MM DD YYYY
8. I HAVE EXAMINED THIS RETURN, AND TO THE BEST OF MY KNOWLEDGE, IT IS CORRECT.
Print Name: _____________________________________
Title: _______________________________
Signature: _______________________________ Date: ___________ Phone: ______-______-________
Remit to: REGIONAL INCOME TAX AGENCY -- P.O. BOX 477900 BROADVIEW HEIGHTS, OH 44147-7900
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FORM REGIONAL INCOME TAX AGENCY: 11A Adjusted Employer's (RITA Ohio)

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Completed 28 December 2022

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