Regional Income Tax Agency
Form          Reconciliation of Income Tax 
     17       Withheld and W-2/1099-NEC Transmittal

1      Tax Year:                                                       3   Total number of W-2’s enclosed:

                                                                       Total number of 1099
Due on or before the last day of February of the following year.                              -NEC enclosed:

                                                                       Total number of employees working in a 
                                                                       RITA member municipality(ies) at year 
Fed. ID #:                                                             end:

Name:                                                                                              IF THIS IS AN AMENDED
                                                                                                   RETURN CHECK HERE
                                                                 Suite:
Address #:                                                                                         OUT OF BUSINESS

Street Name:

City:                                                                                              MOVED OUT OF RITA 

State:                              Zip Code:

                  Workplace Wages                                      Workplace Tax Withheld      Residence Tax Withheld
Period     2

January

February

March

April

May

June

July

August

September

October

November

December

Total       4                              0.00                            0.00                                         0.00

Totals must be distributed by municipality on Page 2 in Section 5.
                                                                                                                    Page
                                                                                                                            1
(if additional space is needed, attach a separate schedule)

                                         Fed. ID #:              

5
  Municipality                                                                                            Number of employees
                                                                                                           at year end

   Workplace Wages                       Workplace               Workplace Tax                   Residence Tax
                                         Tax Rate % 

  Municipality                                                                                            Number of employees
                                                                                                           at year end

   Workplace Wages                       Workplace               Workplace Tax                   Residence Tax
                                         Tax Rate %

  Municipality                                                                                            Number of employees
                                                                                                           at year end

   Workplace Wages                       Workplace               Workplace Tax                   Residence Tax
                                         Tax Rate %

  Municipality                                                                                            Number of employees
                                                                                                           at year end

   Workplace Wages                       Workplace               Workplace Tax                   Residence Tax
                                         Tax Rate %

  Municipality                                                                                            Number of employees
                                                                                                           at year end

   Workplace Wages                       Workplace               Workplace Tax                   Residence Tax
                                         Tax Rate %

6  TOTAL: Must equal totals on Page 1 from Section 4.                                                     7
                                                                                                              Total number of 
   Total Workplace Wages                 Total Workplace Tax                 Total Residence Tax           employees at year end
                                   0.00                              0.00                            0.00                                    0

8 Note: If you file a Form 17 as a professional employer organization (PEO), common pay master, co-employer, or other agent providing 
  payroll services to unrelated third party employers, including, but not limited to, clients, subsidiaries, other companies, etc., you must also 
  provide specific information on each of these employers.  Use Schedule R-17 to report for each employer EIN and Name and to       allocate 
  the Workplace Wages, Workplace Tax Withheld, Residence Tax Withheld and RITA Municipality.

  I have examined this return and to the best of my knowledge it is correct.

9
                         Signature                                           Title                            Date

  Print Name

  Phone:
                                                                                                                                    Page
  Mail to:     Attn RITA                 For OVERNIGHT mail: Attn RITA                                                              2
            P.O. BOX 715170                                                 P.O.BOX 715170
               CINCINNATI, OH 45271-5170                                    895 CENTRAL AVENUE SUITE 600 
  Fax:      440.922.3536                                                    CINCINNATI, OH 45202-5703
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