Rota Individual Income Tax Return
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37
Contact us toll free:
2012
Cleveland
800.860.7482
Regional Income Tax Agency
Columbus
866.721.7482
Youngstown 866.750.7482
RITA Individual Income Tax Return
TDD
440.526.5332
Filing Status:
Your social security number
Spouse’s social security number
Single or Married Filing Separately
3
Joint
2
1
Your first name and middle initial
Last name
If you have an EXTENSION check here
EXTENSION
and attach a copy:
If a joint return, spouse’s first name and middle initial
Last name
If this is an amended return, check here:
Home address (number and street)
Apt #
RITA’s e-File
City, state, and ZIP code
Easy, Fast, Free & Secure
Daytime phone number
Evening phone number
Move Information
Check here if you moved since January 1, 2012, and indicate your change of address. If you moved more than once, supply the
additional move information on a separate sheet.
Date of Move:
Current Address (number and street)
City
State
Zip
City
State
Zip
Prior Address (number and street)
Section A
List all W-2 wages earned in 2012 and the amount of municipal (city) tax withheld while living in a RITA municipality. In general, unless you
moved into or out of a RITA municipality during the year, your taxable wages cannot be less than Medicare wages (Box 5 of your W-2). List all
tax withheld to your resident municipality in Column 3 only (even if you worked in the municipality where you lived). In Column 4, indicate the
name of the municipality in which you or your spouse physically worked. This may be different from the employer’s address shown on the
W-2. If you did not work in a city or village enter “None” in Column 4. DO NOT enter school district tax into columns 2 or 3.
Column 6
Column 1
Column 2
Column 3
Column 4
Column 5
Dates Wages Were
Local/City Tax
Local/City Tax
Wages
Workplace Municipality
Resident Municipality
Earned
Withheld for
Withheld for
(Greater of Box 1,
(Name of city or village
(Name of city or village
Workplace
Resident
From Date
Thru Date
5 or 18 from W-2)
where you worked)
where you lived)
MM/DD/YY
MM/DD/YY
Municipality
Municipality
Enter the total of Column 1 on Page 2, Line 1a; enter the total of Column 2
Totals
0
0
0
on Page 2, Line 4a; and enter the total of Column 3 on Page 2, Line 7a.
To manually calculate your taxes please continue to page 2. Tax balances are due by April 15th, 2013. Submitting an incomplete
CAUTION
form could subject you to penalty and interest if a tax balance is due. If you want RITA to calculate your taxes, please use the online
e-File system at . It is easy to use, secure and will calculate your taxes immediately.
Under penalties of perjury, I declare that I have examined this return, and to the best of my knowledge and belief, it is true, correct, and
accurately lists all amounts and sources of municipal taxable income I received during the tax year.
Your Signature
Date
Preparer’s Signature
Date
Spouse’s Signature if a joint return
Date
Preparer’s Address
ID Number
May RITA discuss this return with the preparer shown above?
Yes
No
Preparer Phone #:
Filing is mandatory for most residents: see “Filing Requirements” on page 1 of the Instructions for Form 37 exemptions.
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