Your first name and middle initial
Current home address (number and street)
City, state, and ZIP code
Reason for Claim
Check the Box below that applies.
•
A separate 10a is
required if you have multiple W-2 f
orms
,
or for each municipality from which a refund is requested.
•
No refunds will be issued without the proper documentation indicated by reason for claim.
(MM/DD/YYYY
)
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 ritaohio.com, select the RITA
municipality in which you worked and review the Special Notes section that relates to the appropriate tax year.
2. Due to COVID-19, 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. Your employer must complete and sign the Employer Certification Parts 1 and 2 on page 2. The availability of a
refund is dependent upon the outcome of pending litigation. Requests will be held until this litigation is resolved.
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. Do Not Use for COVID-19.
4. Employer withheld at a rate higher than the municipality’s tax rate. Attach a copy of your W-2 Form. Your employer
must complete and sign the Employer Certification Parts 1 and 2 on page 2. Do Not Use for COVID-19.
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.
6. Withheld by mistake for the municipality of ________________________ when I actually worked in the municipality of
________________________. 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. Do Not Use for COVID-19.
Work Location Street Address
7. Over-the-road truck driver. The wages of an interstate trucker regularly assigned to drive in more than one state are 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.
8. Military Spouse Residency Relief Act. Attach copies of W-2 Form, Form DD 2058, valid military spouse ID card and
service member’s most recent LES.
9. Other (Indicate Reason). Attach W-2 Form and other applicable documentation. Your employer must complete and sign
the Employer Certification Parts 1 and/or 2 on page 2. Do Not Use for COVID-19.
________________________________________________________________________________________________
10. Refund of overpayment on account if you have already filed Form 37 or are not required to file. Employer certification is
not required.
RITA Municipality for which tax was withheld (from W-2, Box 20). RITA
cannot refund tax withheld to a Non-RITA municipality
3
Amount of income not taxable.
4
Amount of over withholding claimed (Box A-9 on page 2)
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
Provide the social security number of the account to which you want the
amount on line 5 to be credited
SSN of account to be credited
6
Net amount to be refunded. Subtract line 5 from line 4. Amounts $10 or less will not be refunded.
Regional Income Tax Agency
Application for Municipal Income Tax Refund
PO Box 95422
Cleveland, OH 44101-0033
Your social security number
Check here if you worked outside of your
normal place of work in 2020 due to COVID-19.
See Checkbox No. 2 below.