Form 11a - Regional Income Tax Agency
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1
2REGIONAL INCOME TAX AGENCY
FORM
Amended Employer’s Municipal Tax Withholding Statement
11A
Name:
Fed. ID#:
Address #:
Street:
Suite:
–
City:
State:
Zip:
Originally Filed for the Period (mm-dd-yy):
to
Municipality:
Wages
Amount Due/Paid:
$
,
,
.
$
,
,
.
$
,
,
.
$
,
,
.
$
,
,
.
$
,
,
.
$
,
,
.
$
,
,
.
$
,
,
.
Total:
Amended for the Period (mm-dd-yy):
to
Municipality:
Wages
Amount Due/Paid:
$
,
,
.
$
,
,
.
$
,
,
.
$
,
,
.
$
,
,
.
$
,
,
.
$
,
,
.
$
,
,
.
$
,
,
.
TOTAL:
$
,
,
.
PAID WITH ORIGINAL RETURN:
$
,
,
.
BALANCE DUE:
$
,
,
.
OVERPAYMENT:
/
$
,
,
.
CREDIT / PERIOD:
$
,
,
.
REFUND:
If crediting overpayment to multiple municipalities and/or
periods, provide the proper distribution on the back of this form.
*
*
FORM 11A
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