Regional Income Tax Agency Employer’s Municipal Tax Withholding Statement11Fo

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CHECK #: ___________________________

2. TOTAL AMOUNT OFWORKPLACE TAX WITHHELD

3. TOTAL AMOUNT OFRESIDENCE TAX WITHHELD

4. TOTAL AMOUNT DUE AND PAID

MAKE CHECK PAYABLE TO: RITA

I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT.

SIGNATURE

PHONE NUMBER

TITLE DATE

SECTIONA

1. TOTAL WAGES SUBJECTTO WORKPLACE TAX

REGIONAL INCOME TAX AGENCY P.O. BOX 94736 CLEVELAND, OH 44101-4736Fax: 440.922.3536

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MUNICIPALITY WORKPLACE WAGES WORKPLACETAX RATE

WORKPLACETAX WITHHELD

RESIDENCE TAXWITHHELD

$

$

$

$

11LF05A

CHECK HERE IF YOU HAVE ANY CHANGES TO YOURDISTRIBUTION 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

SECTIONB

PRINT NAME

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MUNICIPALITY WORKPLACE WAGES WORKPLACETAX RATE

WORKPLACETAX WITHHELD

RESIDENCE TAXWITHHELD

11LF05B

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SECTIONB

11LF21