Form 10a - Regional Income Tax Agency Application For Municipal Income Tax Refund Page 3
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1
2
33
Form 10-A
Page
Name of employee shown on page 1
Employee’s SSN
Tax Year of Claim
Calculation of Days Worked Outside of RITA Municipality
1 Total workdays available. If you normally work a 5 day workweek and you worked for your employer for
the entire year, enter 260 (52 weeks times 5 days). Otherwise, enter the number of days you normally
1
worked in a week times the number of weeks worked (cannot exceed 260).
2 Days not worked. Enter total number of days included on line 1 that you did not work due to holidays,
2
personal days, sick days, and vacation days
3
3 Total days actually worked. Subtract line 2 from line 1
4 Days worked out of town. A log of days out, destination and reason for travel must be included (see
below). If you worked more than 12 days in another municipality (city or village) that has an income tax,
attach a copy of the tax return filed with that municipality. If you live in a non-RITA municipality that has
4
an income tax, attach a copy of the tax return filed with your resident municipality
5 Days worked in the municipality for which tax was withheld. Subtract line 4 from line 3
5
6 Percentage of wages earned in the municipality. Divide Line 5 by Line 3
6
7 Total municipal taxable wages. Enter the larger of Box 1, 5, 18 from your W-2
7
8 Wages taxable to municipality for which tax was withheld. Multiply Line 6 by Line 7
8
9 Wages not taxable to municipality for which tax was withheld. Subtract Line 8 from Line 7. Enter
9
here and on Page 1, Line 3
Tax Rate
10 Amount of over withholding claimed. Multiply Line 9 by the tax rate of the municipality
10
for which tax was withheld. Enter here and on Page 1, Line 4
Log of Days Out
List the names of the municipalities/locations where you worked while traveling, the reason for your travel, and the number of days
worked at your travel destination. Your own worksheet is acceptable. Use additional paper if necessary.
Work Location
Reason
# Days
Work Location
Reason
# Days
1.
21.
2.
22.
3.
23.
4.
24.
5.
25.
6.
26.
7.
27.
8.
28.
9.
29.
10.
30.
11.
31.
12.
32.
13.
33.
14.
34.
15.
35.
16.
36.
17.
37.
18.
38.
19.
39.
20.
40.
Total number of days worked out of town
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