Form 17 - Rita Page 2

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5
Number of employees
Municipality
at year end
Workplace
Workplace Wages
Workplace Tax
Residence Tax
Tax Rate
$
$
$
%
Number of employees
Municipality
at year end
Workplace
Workplace Wages
Workplace Tax
Residence Tax
Tax Rate
$
$
$
%
Number of employees
Municipality
at year end
Workplace
Workplace Wages
Workplace Tax
Residence Tax
Tax Rate
$
$
$
%
Number of employees
Municipality
at year end
Workplace
Workplace Wages
Workplace Tax
Residence Tax
Tax Rate
$
$
$
%
Number of employees
Municipality
at year end
Workplace
Workplace Wages
Workplace Tax
Residence Tax
Tax Rate
$
$
$
%
Number of employees
Municipality
at year end
Workplace
Workplace Wages
Workplace Tax
Residence Tax
Tax Rate
$
$
$
%
6
7
TOTAL: Must equal totals on Page 1 from Section 4.
Total number of em-
Total Workplace Wages
Total Workplace Tax
Total Residence Tax
ployees at year end
$
$
$
0.00
0
0.00
0.00
I have examined this return and to the best of my knowledge it is correct.
8
Signature
Title
Date
Print Name
Phone:
Page
2
Remit to: REGIONAL INCOME TAX AGENCY - P.O. BOX 477900
BROADVIEW HEIGHTS, OH 44147-7900
17F13

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