Form 11a - Regional Income Tax Agency Page 2
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1
2RITA
REASON:
1
Incorrect Fed. EIN – Correct Fed. EIN is
2
Incorrect Period
3
Incorrect Municipalities
4
Incorrect Amount Paid
5
Additional Municipalities
6
Other – Explanation (Leave a space between each word):
I HAVE EXAMINED THIS RETURN, AND TO THE BEST OF MY KNOWLEDGE, IT IS CORRECT.
__________________________________________________________________________________________________________
11
Name
Title
Date
–
–
Phone
Remit to: REGIONAL INCOME TAX AGENCY – P.O. BOX 94736 CLEVELAND, OHIO 44101-4736
__________________________________________________________________________________________________________
• DISTRIBUTION OF OVERPAYMENT
MUNICIPALITY
FROM PERIOD:
YEAR:
AMOUNT
TO PERIOD:
YEAR:
$
,
,
.
__________________________________________________________________________________________________________
MUNICIPALITY
FROM PERIOD:
YEAR:
AMOUNT
TO PERIOD:
YEAR:
$
,
,
.
__________________________________________________________________________________________________________
MUNICIPALITY
FROM PERIOD:
YEAR:
AMOUNT
TO PERIOD:
YEAR:
$
,
,
.
__________________________________________________________________________________________________________
MUNICIPALITY
FROM PERIOD:
YEAR:
AMOUNT
TO PERIOD:
YEAR:
$
,
,
.
__________________________________________________________________________________________________________
MUNICIPALITY
FROM PERIOD:
YEAR:
AMOUNT
TO PERIOD:
YEAR:
$
,
,
.
FORM 11A B
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