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 12/2023
               www.ccatax.ci.cleveland.oh.us

                                                                                              INSTRUCTIONS
     Line 1 -  Enter the total taxable employment wages as defined in ORC 718.  
     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
BurtonClayton      1.5 1991 176                New CarlisleNew Madison 1.5 5341 538                        ShreveSomerset          1 7551 762                  Revenue Sharing/JEDD/JEDZ (complete below)
Cleveland          2.5 200                     New Miami               1.75 539                            South Russell    1.25 772                           Burton Vill/Twp        1.0 982
Dalton             1.5 252                     New Paris                                1 541              Union            1.5 797                            Clayton/Clay           1.5 984
Edon               1.75 275                    North Baltimore                          1 548              Waynesfield             1 833                       Cle/Warr Hts           2.5 998
Elida              .75 276                     North Randall           2.75 560                            West Milton      1.5 835                            Emerald Park           2.5 993
Geneva-on-the-Lake 1.5 347                     Village of Oakwood                       1 585                                                                  Gateway                2.5 990
Germantown         1.5 348                     Obetz                   2.5 587                                                                                 Cleve/High Hills       2.5 995
Grand Rapids       1 356                       Orwell                  1.5 605                                                                                 High Hills/Cleve       2.5 996
Grand River        2 357         KEEPPauldingTHIS1.1COPY640                                   FOR YOUR RECORDSIX Center                                                               2.5 992
Highland Hills     2.5 371                     Phillipsburg            1.5 659                                                                                 Prairie Obetz          2.5 981
Linndale           2 420                       Pitsburg                                 1 661                                                                  Shaker Sq              2.5 994
Marble Cliff       2 459                       Riverside               2.5 680                                                                                 N. Baltimore JEDD            1 988
Mentor-on-the-Lake 2 495                       Rock Creek                               1 698
Montpelier         1.6 517                     Russells Point                           1 703
Munroe Falls       2.25 533                    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
BurtonClayton      1.5 1991 176                New CarlisleNew Madison 1.5 5341 538                        ShreveSomerset          1 7551 762                  Revenue Sharing/JEDD/JEDZ (complete below)
Cleveland          2.5 200                     New Miami               1.75 539                            South Russell    1.25 772                           Burton Vill/Twp        1.0 982
Dalton             1.5 252                     New Paris                                1 541              Union            1.5 797                            Clayton/Clay           1.5 984
Edon               1.75 275                    North Baltimore                          1 548              Waynesfield             1 833                       Cle/Warr Hts           2.5 998
Elida              .75 276                     North Randall           2.75 560                            West Milton      1.5 835                            Emerald Park           2.5 993
Geneva-on-the-Lake 1.5 347                     Village of Oakwood                       1 585                                                                  Gateway                2.5 990
Germantown         1.5 348                     Obetz                   2.5 587                                                                                 Cleve/High Hills       2.5 995
Grand Rapids       1 356                       Orwell                  1.5 605                                                                                 High Hills/Cleve       2.5 996
Grand River        2 357                       Paulding                1.1 640                                                                                 IX Center              2.5 992
Highland Hills     2.5 371                     Phillipsburg            1.5 659                                                                                 Prairie Obetz          2.5 981
Linndale           2 420                       Pitsburg                                 1 661                                                                  Shaker Sq              2.5 994
Marble Cliff       2 459                       Riverside               2.5 680                                                                                 N. Baltimore JEDD            1 988
Mentor-on-the-Lake 2 495                       Rock Creek                               1 698
Montpelier         1.6 517                     Russells Point                           1 703
Munroe Falls       2.25 533                    Seville                                  1 722

                                                                                                                                                    C of C 120-102 12/2023
                                          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                    Mentor-on-the-Lake  495                                             Phillipsburg   659                    withholding report 
Clayton            199                    Montpelier          517                                             Pitsburg       661                    to be filed with CCA 
Cleveland          200                    Munroe Falls        533                                             Riverside      680                    – Please circle and
Dalton             252                    New Carlisle        534                                             Rock Creek     698                    enter the date of 
Edon               275                    New Madison         538                                             Russells Point 703                    change.
Elida              276                    New Miami           539                                             Seville        722                    1. No longer 
Geneva-on-the-Lake 347                    New Paris           541                                             Shreve         755                    conducts Business 
Germantown         348                    North Baltimore     548                                             Somerset       762                    in a CCA community
Grand Rapids       356                    North Randall       560                                             South Russell  772                    – enter new address
Grand River        357                    Village of Oakwood  585                                             Union          797                    and date of change 
Highland Hills     371                    Obetz               587                                             Waynesfield    833                    below. 
Linndale           420                    Orwell              605                                             West Milton    835                    2. No longer
Marble Cliff       459                    Paulding            640                                                                                   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
                                                                                                                                                    Final Return
Municipality       Code    Tax Withheld   Municipality        Code                Tax Withheld                Municipality   Code Tax Withheld      If this is the last 
                                                                                                                                                    withholding report 
Burton             176                    Mentor-on-the-Lake  495                                             Phillipsburg   659                    to be filed with CCA 
Clayton            199                    Montpelier          517                                             Pitsburg       661                    – Please circle and
Cleveland          200                    Munroe Falls        533                                             Riverside      680                    enter the date of 
Dalton             252                    New Carlisle        534                                             Rock Creek     698                    change.
Edon               275                    New Madison         538                                             Russells Point 703                    1. No longer conducts 
Elida              276                    New Miami           539                                             Seville        722                    Business in a CCA 
Geneva-on-the-Lake 347                    New Paris           541                                             Shreve         755                    community – enter 
                                                                                                                                                    new address and date
Germantown         348                    North Baltimore     548                                             Somerset       762                    of change below. 
Grand Rapids       356                    North Randall       560                                             South Russell  772
Grand River        357                    Village of Oakwood  585                                             Union          797                    2. No longer
Highland Hills     371                    Obetz               587                                             Waynesfield    833                    withholding
                                                                                                                                                    residence tax for CCA 
Linndale           420                    Orwell              605                                             West Milton    835                    community.
Marble Cliff       459                    Paulding            640
                                                                                                                                                    3. No longer has 
                                                                                               Total Residence Tax   ►                              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.