Instructions For Form Cca-102 - Employer'S Return Of Income Tax Withheld Page 2

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GENERAL INSTRUCTIONS FOR FORM CCA-102
WHO MUST FILE - Employers doing business within any CCA community with one or more employees must file and pay employment tax as
defined in ORC 718.03.
If you temporarily discontinue paying wages, you must nevertheless file a return with CCA. If you no longer expect to pay wages subject to the tax
reportable on this form, you must file a "FINAL RETURN" with explanation shown on the back of this form.
After you have once filed a return, a preprinted Form CCA-102 will be mailed to you.
You may also download a blank return at Be sure to fill in all necessary information in order to avoid penalty.
WHAT INCOME IS TAXABLE - Qualifying wages as defined in ORC Section 718.03 (Typically, FICA/Medicare wages as reportable in Box 5 of
Federal Form W-2 with two possible additions for stock options and sub pay.)
Effective 01-01-04
IRC Sec. 125 cafeteria plans are not taxable.
PENALTY & INTEREST - The law provides penalties for late filing of a return and payments thereof. Penalties also are imposed by law for failure
to pay, collect or truthfully account for and pay over tax, keep records, make returns, for false or fraudulent returns or for submitting bad checks.
Penalty rate is 10% and Interest rate is 1-1/2% per month for late payments. See specific ordinance for variances.
ALLOCATION OF RESIDENCE TAX
Municipality Code
Tax Withheld
Municipality Code
Tax Withheld
Municipality Code
Tax Withheld
Municipality Code
Tax Withheld
Final Return
Ada
002
Grand River
357
North Perry Village
555
Timberlake
788
If this is the last
withholding report to
Andover
006
Highland Hills
371
North Randall
560
Wadsworth
815
be filed with CCA -
Barberton
025
Liberty Center
408
Norton
575
Warrensville Hts.
830
Please circle and
Bradner
117
Linndale
420
Oakwood Village
585
Willoughby
870
enter the date of
Bratenahl
120
Madison Village
455
Orwell
605
Willoughby Hills
880
change.
Painesville
Burton
176
Medina
487
610
1. No longer con-
Chardon
185
Paulding
640
Mentor
490
ducts Business in a
C.C.A. community -
Cleveland
200
Mentor-on-the-Lake
495
Peninsula
645
enter new address
Creston
238
Metamora
497
Perry
655
and date of change
Rock Creek
Cridersville
239
Middlefield
510
698
below.
Dunkirk
266
Munroe Falls
533
Rocky River
700
2. No longer
Gates Mills
330
New Franklin
537
Russells Point
703
withholding
Geneva-on-the-Lake
347
Seville
Northfield Village
545
722
residence tax for
C.C.A. community.
Grand Rapids
356
North Baltimore
548
South Russell
772
3. No longer has
employees but still
conducts business in
Total Residence Tax
a C.C.A. community.
4. Merged -
New Federal ID#
EXPLANATION OF ADJUSTMENT - Amount $
Adjustment for period end
5. Liquidated
Reason
6. Other
ALLOCATION OF RESIDENCE TAX
Municipality Code
Tax Withheld
Municipality Code
Tax Withheld
Municipality Code
Tax Withheld
Municipality Code
Tax Withheld
Final Return
Ada
002
Grand River
357
North Perry Village
555
Timberlake
788
If this is the last
withholding report to
Andover
006
Highland Hills
371
North Randall
560
Wadsworth
815
be filed with CCA -
Barberton
025
Liberty Center
408
Norton
575
Warrensville Hts.
830
Please circle and
Bradner
117
Oakwood Village
Linndale
420
585
Willoughby
870
enter the date of
Bratenahl
120
Madison Village
455
Orwell
605
Willoughby Hills
880
change.
Burton
176
Medina
487
Painesville
610
1. No longer con-
Chardon
185
Mentor
490
Paulding
640
ducts Business in a
C.C.A. community -
Cleveland
200
Mentor-on-the-Lake
495
Peninsula
645
enter new address
Creston
238
Metamora
497
Perry
655
and date of change
Cridersville
239
Middlefield
510
Rock Creek
698
below.
Dunkirk
266
Munroe Falls
533
Rocky River
700
2. No longer
Gates Mills
330
New Franklin
537
Russells Point
703
withholding
Geneva-on-the-Lake
347
Northfield Village
545
Seville
722
residence tax for
C.C.A. community.
Grand Rapids
356
North Baltimore
548
South Russell
772
3. No longer has
employees but still
conducts business in
Total Residence Tax
a C.C.A. community.
4. Merged -
New Federal ID#
IF NAME OR
EXPLANATION OF ADJUSTMENT - Amount $
NAME
ADDRESS IS NOT
CORRECT AS SHOWN,
Adjustment for period end
ADDRESS
SHOW NEW
5. Liquidated
ADDRESS HERE.
CITY
ZIP
Reason
6. Other
DATE OF CHANGE

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