CCA – DIVISION OF TAXATION                                                                                                                                              EMPLOYER’S RETURN
                   205 W SAINT CLAIR AVE
                   CLEVELAND OH 44113-1503                                                                                                                                           OF INCOME TAX WITHHELD
                   216.664.2070    800.223.6317                                                                                                                                                       C of C 120-102 8/2022
                   www.ccatax.ci.cleveland.oh.us
                                                                                              INSTRUCTIONS
     Line 1 -  Enter the total taxable employment wages as defined in ORC 718.  Do not include wages from individuals under the age of 18.  Exceptions: Montpelier, Munroe Falls, New Paris,   
              Oakwood, Obetz, Phillipsburg, and Riverside have no age limit; Grand River, Rushsylvania and West Milton under the age of 16; Geneva-On-The-Lake under the age of 15. New
              Carlisle indviduals 16 and 17 years old who earn $2500.00 or more are subject to the tax.
     Line 2 - Enter the amount of employment tax withheld.  See employment municipality for tax rate.  Allocation of employment tax withheld must be detailed on the front of this form.
     Line 3 -  Enter the amount of residence tax withheld.  Allocation of residence tax must be detailed on the reverse of this form.
     Line 4 - Adjustment of income tax withheld.  Line 4 should be used for the correction of errors made in withholding of income tax from wages paid in prior quarters.  Any amount shown on   
              Line 4 must be explained on the reverse of this form.
     Line 5 -  Balance Due / Paid herewith. Make checks payable to the CCA – Division of Taxation.  The amount indicated must be paid with the return by the due date indicated and  
              allocated to the City of Employment unless work is performed in a non-taxing area.  Tax withheld in a non-taxing area reverts back to the City of Residence of the employee.
Signature- Sign, date and enter phone number before returning this form.  A return is not considered filed until signed.  Name and Address changes should be made on the reverse of this form.
Date Due - Monthly filings are due by the 15th day of the month following the end of the withholding period. Semimonthly filings are due by the 3rd banking day after the 15th day of the 
                   withholding period andKEEPthe 3rd banking dayTHISafter the last dayCOPYof the withholdingFORperiod. QuarterlyYOURfilings are due onRECORDSor before the last day of the month following the last day of each   
                   calendar quarter.                                                                                            ALLOCATION OF EMPLOYMENT AND RESIDENCE TAX REMITTED
                                                                                                                                            MUST BE COMPLETED TO AVOID PENALTY
                                                                                                                                Employers which withhold more than $200.00 per month must file monthly.
                                                                                                                                Employers always withholding $200.00 or less per month can file quarterly.
                                                                                                            1.  Total Employment Wages                                      2.  Total Employment Taxes
                                                                                                             Subject to Withholding                                          (allocate below)
                                                                                                             Emp Code                FEDERAL ID #                 File Code                        ►
                                                                                                                                                                            3.  Total Residence Taxes
                                                                                                                                                                             (allocate on reverse) ►
                                                                                                                                For the period                              4.  Adjustments
                                                                                                                                To                                           (explain on Reverse) ►
                                                                                                                         Due on or before:                                  5.  TOTAL TAXES
                                                                                                                                                                             ALLOCATED             ►
                                                                                                                                                                             Make checks payable to CCA.
                                                                                                                                            ALLOCATION OF EMPLOYMENT TAX WITHHELD
     Municipality   Rate% Code        Tax Withheld       Municipality     Rate% Code          Tax Withheld   Municipality       Rate% Code          Tax Withheld             Municipality      Rate% Code  Tax Withheld
 ClaytonBurton      1.51 176199                     NewNew MiamiMadison   1.751539538                        ShreveSouth Russell1.251772755                                  Revenue Sharing/JEDD/JEDZ (complete below)
 Cleveland          2.5 200                         New Paris                           1 541                Union              1.5 797                                      Burton Vill/Twp   1.0 982
 Dalton             1 252                           North Baltimore                     1 548                Waynesfield                1 833                                Clayton/Clay      1.5 984
 Elida              .75 276                         North Randall         2.75 560                           West Milton        1.5 835                                      Cle/Warr Hts      2.5 998
 Geneva-on-the-Lake 1.5 347                         Village of Oakwood                  1 585                                                                                Emerald Park      2.5 993
 Germantown         1.5 348                         Obetz                 2.5 587                                                                                            Gateway           2.5 990
 Grand Rapids       1 356                           Orwell                1.5 605                                                                                            Cleve/High Hills  2.5 995
 Grand River        2 357                           Paulding              1.1 640                                                                                            High Hills/Cleve  2.5 996
 Highland Hills     2.5 371           KEEPPhillipsburgTHIS1.5COPY659                             FOR YOUR RECORDSIX Center                                                                     2.5 992
 Linndale           2 420                           Pitsburg                            1 661                                                                                Prairie Obetz     2.5 981
 Marble Cliff       2 459                           Riverside             2.5 680                                                                                            Shaker Sq         2.5 994
 Mentor-on-the-Lake 2 495                           Rock Creek                          1 698                                                                                N. Baltimore JEDD       1 988
 Montpelier         1.6 517                         Rushsylvania                        1 702
 Munroe Falls       2.25 533                        Russells Point                      1 703
 New Carlisle       1.5 534                         Seville                             1 722
              SHOW CHANGE OF ADDRESS OR CHANGE OF                                                                               Employers which withhold more than $200.00 per month must file monthly.
     FILING STATUS ON THE REVERSE SIDE OF THIS FORM                                                                      Employers always withholding $200.00 or less per month can file quarterly.
          CCA – DIVISION OF TAXATION                                                          Make checks payable to CCA.                   EMPLOYER’S RETURN OF INCOME TAX WITHHELD
          205 W SAINT CLAIR AVE
          CLEVELAND OH 44113-1503                                                                           1.  Total Employment Wages                                      2.  Total Employment Taxes
                                                                                                             Subject to Withholding                                          (allocate below)      ►
                                                                                                             Emp Code                FEDERAL ID #                 File Code 3.  Total Residence Taxes
                                                                                                                                                                             (allocate on reverse) ►
                                                                                                                                For the period                              4.  Adjustments
                                                                                                                                To                                           (explain on Reverse) ►
Signature                             Title                      Co. Phone               Date                            Due on or before:                                  5.  TOTAL TAXES
I have examined this return and to the best of my knowledge, it is correct and complete                                                                                      ALLOCATED             ►
                                                                ALLOCATION OF EMPLOYMENT TAX WITHHELD
 ClaytonBurton      1.51 176199                     NewNew MiamiMadison   1.751539538                        ShreveSouth Russell1.251772755                                  Revenue Sharing/JEDD/JEDZ (complete below)
 Cleveland          2.5 200                         New Paris                           1 541                Union              1.5 797                                      Burton Vill/Twp   1.0 982
 Dalton             1 252                           North Baltimore                     1 548                Waynesfield                1 833                                Clayton/Clay      1.5 984
 Elida              .75 276                         North Randall         2.75 560                           West Milton        1.5 835                                      Cle/Warr Hts      2.5 998
 Geneva-on-the-Lake 1.5 347                         Village of Oakwood                  1 585                                                                                Emerald Park      2.5 993
 Germantown         1.5 348                         Obetz                 2.5 587                                                                                            Gateway           2.5 990
 Grand Rapids       1 356                           Orwell                1.5 605                                                                                            Cleve/High Hills  2.5 995
 Grand River        2 357                           Paulding              1.1 640                                                                                            High Hills/Cleve  2.5 996
 Highland Hills     2.5 371                         Phillipsburg          1.5 659                                                                                            IX Center         2.5 992
 Linndale           2 420                           Pitsburg                            1 661                                                                                Prairie Obetz     2.5 981
 Marble Cliff       2 459                           Riverside             2.5 680                                                                                            Shaker Sq         2.5 994
 Mentor-on-the-Lake 2 495                           Rock Creek                          1 698                                                                                N. Baltimore JEDD       1 988
 Montpelier         1.6 517                         Rushsylvania                        1 702
 Munroe Falls       2.25 533                        Russells Point                      1 703
 New Carlisle       1.5 534                         Seville                             1 722

                                                                                                                                                    C of C 120-102 8/2022
                                          GENERAL INSTRUCTIONS FOR FORM CCA – 102
WHO MUST FILE – Employers doing business within any CCA community with one or more employees must file and pay employment tax as defined in ORC 718.
If you temporarily discontinue paying wages, you must nevertheless file a return with CCA. If you no longer expect to pay wages subject to the tax reportable on this form, you must
file a ‘FINAL RETURN’ with explanation shown below. After you have once filed a return, a preprinted Form CCA-102 will be mailed to you. Blank forms can also be downloaded at
www.ccatax.ci.cleveland.oh.us. Remit timely and complete all necessary information in order to avoid penalty. 
WHAT INCOME IS TAXABLE – Qualifying wages as defined in ORC Section 718. (Typically, FICA/Medicare wages are reportable in Box 5 of Federal Form W-2 with two possible 
additions for stock options and sub pay.) 
PENALTY & INTEREST – The law provides penalties for late filing of a return and payments thereof. Penalties also are imposed by law for failure to pay, for making false or fraudulent 
returns or for submitting bad checks. Each return filed and/or paid past the due date may incur a 50% penalty. Interest on the upaid balance may accrue monthly using the interest 
prescribed in ORC 718. See community ordinances for variances.

                                          ALLOCATION OF RESIDENCE TAXES WITHHELD
Municipality        Code   Tax Withheld   Municipality        Code                 Tax Withheld               Municipality   Code Tax Withheld      Final Return
                                                                                                                                                    If this is the last 
Burton              176                   Montpelier          517                                             Pitsburg       661                    withholding report 
Clayton             199                   Munroe Falls        533                                             Riverside      680                    to be filed with CCA 
Cleveland           200                   New Carlisle        534                                             Rock Creek     698                    – Please circle and 
Dalton              252                   New Madison         538                                             Rushsylvania   702                    enter the date of 
Elida               276                   New Miami           539                                             Russells Point 703                    change.
Geneva-on-the-Lake  347                   New Paris           541                                             Seville        722                    1. No longer 
Germantown          348                   North Baltimore     548                                             Shreve         755                    conducts Business 
Grand Rapids        356                   North Randall       560                                             South Russell  772                    in a CCA community 
Grand River         357                   Village of Oakwood  585                                             Union          797                    – enter new address 
Highland Hills      371                   Obetz               587                                             Waynesfield    833                    and date of change 
Linndale            420                   Orwell              605                                             West Milton    835                    below. 
Marble Cliff        459                   Paulding            640                                                                                   2. No longer
Mentor-on-the-Lake  495                   Phillipsburg        659                                                                                   withholding
                                                                                                Total Residence Tax   ►                             residence tax for 
                                                                                                                                                    CCA community.
                                                                                                                                                    3. No longer has 
                                                                                                                                                    employees but still 
                                                                                                                                                    conducts Business 
                                                                                                                                                    in a CCA
                                                                                                                                                    community
                                                                                                                                                    4. Merged –
                                                                                   EXPLANATION OF ADJUSTMENT – Amount $                             New Federal ID#
                                                                                   Adjustment for period end                                         
                                                                                   Reason                                                           5. Liquidated
                                                                                                                                                    6. Other
                                                                                                                                                     
                                          ALLOCATION OF RESIDENCE TAXES WITHHELD
Municipality        Code   Tax Withheld   Municipality        Code                 Tax Withheld               Municipality   Code Tax Withheld      Final Return
                                                                                                                                                    If this is the last 
Burton              176                   Montpelier          517                                             Pitsburg       661                    withholding report 
Clayton             199                   Munroe Falls        533                                             Riverside      680                    to be filed with CCA 
Cleveland           200                   New Carlisle        534                                             Rock Creek     698                    – Please circle and 
                                                                                                                                                    enter the date of 
Dalton              252                   New Madison         538                                             Rushsylvania   702                    change.
Elida               276                   New Miami           539                                             Russells Point 703
Geneva-on-the-Lake  347                   New Paris           541                                             Seville        722                    1. No longer conducts 
                                                                                                                                                    Business in a CCA 
Germantown          348                   North Baltimore     548                                             Shreve         755                    community – enter 
Grand Rapids        356                   North Randall       560                                             South Russell  772                    new address and date 
Grand River         357                   Village of Oakwood  585                                             Union          797                    of change below. 
Highland Hills      371                   Obetz               587                                             Waynesfield    833                    2. No longer
Linndale            420                   Orwell              605                                             West Milton    835                    withholding
Marble Cliff        459                   Paulding            640                                                                                   residence tax for CCA 
Mentor-on-the-Lake  495                   Phillipsburg        659                                                                                   community.
                                                                                                Total Residence Tax   ►                             3. No longer has 
                                                                                                                                                    employees but still 
                                                                                                                                                    conducts Business in 
                                                                                                                                                    a CCA
                                                                                                                                                    community
                                                                                                                                                    4. Merged –
                   NAME                                                                                                                             New Federal ID#
                                                                                   EXPLANATION OF ADJUSTMENT – Amount $                              
                   ADDRESS                                                                                                                          5. Liquidated
                                                                                   Adjustment for period end 
                                                                                                                                                    6. Other
                                                                                   Reason                                                            
                   DATE OF CHANGE                                                                 
                    If Name or Address is not correct as shown, show changes above.