Form 10a - Regional Income Tax Agency Application For Municipal Income Tax Refund (Page 2 of 3) in pdf

Form 10-A

Page

Name of employee shown on page 1

Employee’s SSN

Tax Year of Claim

Employer Certification

A. Refund/Credit Calculation

A 1 Total Wages from employee’s W-2 Form

A-1

2 Enter name of municipality for which tax was withheld

A-2

3 Amount of municipal tax withheld to the municipality indicated on line A-2

A-3

4 Name of the municipality where the employee

physically performed the work or services. If the

employee did not work within the limits of a

municipality enter “None” on line A-4, skip lines A-5,

A-6 and A-7, and enter -0- on line A-8

A-4

5 Enter the amount of municipal taxable wages earned in the municipality

indicated on line A-4

A-5

6 Enter the tax rate of the municipality indicated on line A-4

A-6

7 Tax due to municipality where employee physically worked. Multiply line A-5

by the tax rate on line A-6

A-7

8 If the municipality indicated on line A-4 is a RITA municipality, enter the amount from line A-7;

otherwise enter -0-

A-8

9 Amount of Over-withheld tax to be refunded or credited. Subtract line A-8 from line A-3

A-9

B. Employee’s Home Address

According to our records, this employee’s home address for the period covered by this claim was:

Employee’s Home Street Address

City

State

Zip

C. Employee’s Employment Dates

If the employee is still employed, enter “n/a” as the date of separation.

Date of Hire

Date of Separation

D. Employer Representative’s Signature

The undersigned employer representative states that during the year referenced above the employer withheld municipal income tax from the above

named employee in excess of the employee’s liability as calculated above; that the above referenced employee was employed during the period

referenced above; that the employer has examined this claim for refund in its entirety including any accompanying schedules and statements; and that

the employer representative can attest that the information reported on this claim is true and accurate.

In addition, the undersigned employer representative verifies that no portion of the over-withheld tax has been or will be refunded directly to the

employee by the employer, and that no adjustments to the employer’s withholding account related to this claim have been or will be made.

Representative’s Signature

Representative’s Title

Date

Representative’s Phone Number

Print Representative’s Name

Print Representative’s Title

Employee’s Signature

Under penalties of perjury, I declare that I have examined this claim, and to the best of my knowledge and belief, it is true, correct and complete. I

understand that this information may be released to the tax administrator of the municipality of residence and the Internal Revenue Service. I further

understand that if this refund changes my RITA residence tax, an amended return must be filed before the refund will be issued. I also understand that if

I have a balance due for a prior year or years, this refund will be applied to that balance due before issuance.

Employee’s Signature

Date

Employee’s Daytime Phone

Employee’s Evening Phone

To avoid delays or a denial of your refund:

Mail with required documentation to:

•

Mail this form along with the required documents

Regional Income Tax Agency

indicated under your “Reason for Claim” on page

PO Box 477900