Fillable SECTION A 1. TOTAL WAGES SUBJECT FOR THE (RITA Ohio)

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SECTION A 1. TOTAL WAGES SUBJECT FOR THE (RITA Ohio)

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Regional Income Tax Agency
Employer’s Municipal Tax Withholding Statement
11
Form
Page
1
2. TOTAL AMOUNT OF
WORKPLACE TAX WITHHELD
3. TOTAL AMOUNT OF
RESIDENCE TAX WITHHELD
PHONE NUMBER
TITLE
DATE
SECTION
A
1. TOTAL WAGES SUBJECT
TO WORKPLACE TAX
REGIONAL INCOME TAX AGENCY
P.O. BOX 94736 CLEVELAND, OH 44101-4736
Fax: 440.922.3536
MUNICIPALITY WORKPLACE WAGES
WORKPLACE
TAX WITHHELD
RESIDENCE TAX
WITHHELD
11LF05A
CHECK HERE IF YOU HAVE ANY CHANGES TO YOUR
DISTRIBUTION AND COMPLETE SECTION B ON THIS FORM.
SECTION B MUST BE COMPLETED. SECTION A MUST EQUAL SECTION B.
NEGATIVE AMOUNTS ARE NOT ACCEPTABLE.
DUE ON OR BEFORE
FED. ID #:
NAME:
ADDRESS #:
SUITE:
STREET NAME:
CITY:
STATE:
ZIP CODE:
FOR THE PERIOD
TO
SECTION
B
4.
TOTAL AMOUNT DUE AND PAID
MAKE CHECK PAYABLE TO: RITA CHECK #:
I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT.
SIGNATURE
PRINT NAME
PRINT FORM
Page
2
MUNICIPALITY WORKPLACE WAGES
WORKPLACE
TAX WITHHELD
RESIDENCE TAX
WITHHELD
11LF05B
B
11LF22
SECTION
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SECTION A 1. TOTAL WAGES SUBJECT FOR THE (RITA Ohio)

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Completed 16 March 2022

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