Form 11a - Amended Employer'S Municipal Tax Withholding Statement Page 2

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Reason for Amending
(Must Be Provided)
6.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Distribution of Overpayment
(From Section 5)
7.
Municipality
Amount
Distribute Credit to
Tax Period
____________________
$__________________
______/______/_________
MM
DD
YYYY
____________________
$__________________
______/______/_________
MM
DD
YYYY
____________________
$__________________
______/______/_________
MM
DD
YYYY
____________________
$__________________
______/______/_________
MM
DD
YYYY
____________________
$__________________
______/______/_________
MM
DD
YYYY
____________________
$__________________
______/______/_________
MM
DD
YYYY
____________________
$__________________
______/______/_________
MM
DD
YYYY
____________________
$__________________
______/______/_________
MM
DD
YYYY
8. I HAVE EXAMINED THIS RETURN, AND TO THE BEST OF MY KNOWLEDGE, IT IS CORRECT.
Print Name: _____________________________________
Title: _______________________________
Signature: _______________________________ Date: ___________ Phone: ______-______-________
Remit to: REGIONAL INCOME TAX AGENCY -- P.O. BOX 477900 BROADVIEW HEIGHTS, OH 44147-7900

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