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Regional Income Tax Agency
Application for Municipal Income Tax Refund
Form PO Box 95422
10A Cleveland, OH 44101-0033
Your social security number Tax year of claim To avoid delays in your refund request, please review the
2023 instruction page for guidelines and claim specifics.
Your first name and middle initial Last name If filing a Form 37 and 10A, attach 10A to your completed
return and mail them together to the Form 10A address.

Current home address (number and street) Apt # Frequently asked questions regarding Refunds can be
found on ritaohio.com under FAQs/Individual FAQ/Refunds.
City, state, and ZIP code
Contact phone number: ___________________________________
Reason for Claim
Check the Box below that applies.
• A separate 10 Ais required if you have multiple W-2 forms, or for each municipality from which a refund is requested.
• No refunds will be issued without the proper documentation indicated by reason for claim.
(MM/DD/YYYY)
1. Age Exemption. Date of Birth________________ Attach a copy of your W-2 form and proof of birthdate (birth certificate, driver’s
license, etc.). If you were under age for only part of the year, you must either: (1) have your employer sign the completed Employer
Certification on page 2; or (2) attach a copy of your pay stub for the pay period in which your birthday fell. Exceptions to the
under 18 years of age exemption exist. For age exemption qualifications, visit ritaohio.com, select the RITA municipality in which
you worked and review the Special Notes section that relates to the appropriate tax year.
2. Days Worked From Home. Days worked outside of municipality for which the employer withheld tax, and instead you
worked from home (remote). Attach a copy of your W-2 Form, a completed Log of Days Out Worksheet on page 3, and a
completed Calculation ofDays Worked Out of RITA on page 3. Your employer must sign the Employer Certification on page 2.
3. Other Days Worked Outside of municipality for which the employer withheld tax (other than days worked at home). Attach a
copy of your W-2 Form, a completed Log of Days Out Worksheet on page 3, and a completed Calculation ofDays Worked Out of
RITA on page 3. In addition, your employer must sign the Employer Certification on page 2.
4. Employer withheld at a rate higher than the employment municipality’s tax rate. Attach a copy of your W-2 Form and a
completed Calculation of Overpayment on page 2. Your employer must sign the Employer Certification on page 2. Do Not Use fo9.
5. Employer withheld too much (over-withheld) residence municipality tax. Attach a copy of your W-2 Form. Your employer
must sign the Employer Certification on page 2.
6. Withheld by mistake for the municipality of ________________________ when I actually worked in the municipality of
________________________. Attach a copy of your W-2 Form. Your employer must sign the Employer Certification on page 2.
Indicate the address where you actually worked in the box below.
Work Location Street Address City State Zip

7. Over-the-road truck driver. The wages of an interstate truck driver regularly assigned to drive in more than one state are
only taxable by the driver’s municipality of residence. Intrastate truck drivers may be eligible to receive up to a 90% refund
from their principal place of work. (A logging of your work locations, to support a refund of the tax withheld from your principal place
of work is required). Attach a copy of your W-2. In addition, your employer must sign the Employer Certification (pg. 2).
8. Military Spouse Residency Relief Act. Attach copies of W-2 Form, Form DD 2058, valid military spouse ID card and
service member’s most recent LES. Only the completion of the Claim Summary below is required.
9. Other (Indicate Reason). Attach W-2 Form and other applicable documentation, and a completed Calculation of Overpayment
on page 2. Your employer must sign the Employer Certification on page 2.
________________________________________________________________________________________________________
10. Refund of overpayment on account if you have already filed Form 37 or you are not required to file. Employer certification is not
required. This reason should not be selected if requesting a refund for taxes withheld by your employer. Use
applicable reasons 1-9 for requests for taxes withheld by your employer.
Claim Summary – Submit one claim per form. Please complete a separate 10A if multiple employers/municipalities exist.
1 Employer Federal ID # Employer Name
1
2 RITA Municipality for which tax was withheld (from W-2, Box 20). RITA
cannot refund tax withheld to a Non-RITA municipality 2
3 Amount of income not taxable. Enter -0- for reasons 4 and 5. For all other reasons enter the
amount of wages you are claiming are nottaxable 3
4 Amount of over withholding claimed (Box A-9 on page 2 or Line 10 on page 3) 4
5 Amount of over withholding you want applied as a payment to your individual or joint account
instead of being refunded to you. Enter -0- if you want all of your refund sent to you 5
Provide the social security number of the account to which you want the SSN of account to be credited
amount on line 5 to be credited
6 Net amount to be refunded. Subtract line 5 from line 4. Amounts $10 or less will not be refunded. 6

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Form 10-A                                                                                                                                             Page 2 

Name of employee shown on page 1                                                                Employee’s SSN                 Tax Year of Claim 
                                                                                                                                         2023

Calculation of Overpayment – Complete for Refund Claim Reasons 4 or 9 
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  List the complete address where 
      the employee physically performed the work or 
      services. If the employee did not work within the            Work location street address 
      limits of a municipality, skip lines A-5, A-6 and A-7, 
      and enter -0- on line A-8                              A-4 City, State, Zip Code 
   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. 
      Amounts $10 or less will not be refunded or credited. Enter total on Page 1, line 4.                                 A-9
B. Employee’s Home Address
   The 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 

Employer Certification 
Employer Representative’s Explanation of Reason for Refund and 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; 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 with respect to time worked in the municipality withheld 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            Explanation of Reason for Refund(example–“taxpayer works from home 4 days”) 
Taxpayer’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 resident or  workplace municipality 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 an unpaid balance due, this refund will be applied to that balance due. 

Taxpayer’s Signature                 Date                                    Taxpayer’s Daytime Phone                      Taxpayer’s Evening Phone 

To avoid delays: 
•  Mail this form along with the required documents                               Mail with required documentation to: 
   indicated under your “Reason for Claim” on page                                              Regional Income Tax Agency 
   1 to the address shown at right; and                                                         PO Box 95422 
•  If filing Form 37, attach the 10A to the completed                                           Cleveland, OH 44101-0033 
   return and mail them together.

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Form 10-A Page 3

Name of employee shown on page 1 Employee’s SSN Tax Year of Claim
2023

Calculation of Days Worked Outside of RITA Municipality – Complete for Refund Claim
Reasons 2 or 3.
1 Total workdays available.If you normally work a 5 day work week 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
worked in a week times the number of weeks worked (cannot exceed 260). 1
2 Days not worked. Enter total number of days included on line 1 that you did not work due to holidays,
personal days, sick days, and vacation days 2
3 Total days actually worked. Subtract line 2 from line 1 3
4 Days worked outside of the municipality for which tax was withheld. A log of days out must be included
(see below). For purposes of this refund claim, if you worked in another municipality that has an income
tax, the wages earned in that municipality are subject to tax in that municipality. 4
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. For most taxpayers, this is the larger of Box 5 or 18 from your W-2 7
7A Amount of municipal tax withheld to the municipality (W-2 Box 19) 7A
8 Wages taxable to municipality for which tax was withheld. Multiply line 6 by line 7 8
Tax Rate
8A Multiply line 8 by workplace tax rate 8A
9 Wages not taxable to municipality for which tax was withheld. Subtract line 8 from line 7. Enter here
and on Page 1, line 3 9
10 Amount of over withholding claimed. Amount of over withholding claimed. Subtract line 8A from line
7A. Enter here and on Page 1, line 4 10

Log of Days Out
List the names of the municipalities/locations where you worked while working outside of the municipality for which tax was withheld, and
the number of days worked in those municipalities/locations. Your own worksheet is acceptable. Use additional paper if necessary.
Travel Work Location Reason # Days Travel Work Location Reason # Days
Date/s Date/s

Total number of Days worked outside of municipality
for which the employer withheld tax

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