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RITA’s eFile
Contact us toll free:
11
Regional Income Tax Agency
Cleveland
800.860.7482
Easy, Fast, Free & Secure
Columbus
866.721.7482
Youngstown
866.750.7482
RITA Employer’s Municipal Tax
TDD
440.526.5332
Withholding Statement
Fax
440.922.3536
SECTION
A
1. TOTAL WAGES SUBJECT
FOR THE PERIOD
$
TO WORKPLACE TAX
11LF05A
2. TOTAL AMOUNT OF
TO
$
WORKPLACE TAX WITHHELD
DUE ON OR BEFORE
3. TOTAL AMOUNT OF
$
RESIDENCE TAX WITHHELD
FED. ID #:
4. TOTAL AMOUNT DUE AND PAID
$
NAME:
MAKE CHECK PAYABLE TO: RITA
CHECK #: ___________________________
I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT.
ADDRESS #:
SUITE:
SIGNATURE
STREET NAME:
PRINT NAME
CITY:
TITLE
DATE
STATE:
ZIP CODE:
PHONE NUMBER
SECTION
SECTION B MUST BE COMPLETED. SECTION A MUST EQUAL SECTION B.
CHECK HERE IF YOU HAVE ANY CHANGES TO YOUR
B
NEGATIVE AMOUNTS ARE NOT ACCEPTABLE.
DISTRIBUTION AND COMPLETE SECTION B ON THIS FORM.
MUNICIPALITY
WORKPLACE WAGES
WORKPLACE
WORKPLACE
RESIDENCE TAX
TAX RATE
TAX WITHHELD
WITHHELD
%
%
%
%
%
%
%
%
%
%
%
%
%
REGIONAL INCOME TAX AGENCY
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P.O. BOX 94736 CLEVELAND, OH 44101-4736
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