DRAFT  

Do not file draft forms.  Although we do not expect this draft to change 

significantly before we publish the final version, we will not post the final 

version until after year-end.   

                            PRINT FORM                                                                                      RESET FORM

                     Regional Income Tax Agency 
       Form    Employer Municipal Tax Withholding Statement
       11

                                                                          SECTION
                                                                                  A

                       FOR THE PERIOD                                     1. TOTAL WAGES SUBJECT
                                                                          TO WORKPLACE TAX
                     11LF05A
                            TO                                            2. TOTAL AMOUNT OF
                                                                          WORKPLACE TAX WITHHELD
DUE ON OR BEFORE
                                                                          3. TOTAL AMOUNT OF
                                                                          RESIDENCE TAX WITHHELD
FED. ID #:
                                                                          4. TOTAL AMOUNT DUE AND PAID 
NAME:
                                                                          MAKE CHECK PAYABLE TO: RITA            CHECK #:   
ADDRESS #:                                              SUITE:            I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT.

STREET NAME:                                                              SIGNATURE
                                                                          PRINT NAME 
CITY:
                                                                          TITLE                          DATE
STATE:                      ZIP CODE:
                                                                          PHONE NUMBER

SECTION      SECTION B MUST BE COMPLETED. SECTION A MUST EQUAL SECTION B.                   CHECK  HERE  IF  YOU  HAVE  ANY  CHANGES  TO  YOUR
       B     NEGATIVE AMOUNTS ARE NOT ACCEPTABLE.                                           DISTRIBUTION AND COMPLETE SECTION B ON THIS FORM.

MUNICIPALITY                          WORKPLACE WAGES                                       WORKPLACE                       RESIDENCE TAX
                                                                                            TAX WITHHELD                    WITHHELD

                                DRAFT 

RegularREGIONALMail: INCOME TAX AGENCY 
Single Distributor                                Regular Mail:             Overnight Mail:                                                   Page
P.O. BOX 94983                                  Multiple Distributors     4910 Tiedeman Road 
CLEVELAND, OH 44101-4983                        P.O. BOX 94736            BROOKLYN, OH 44144                                                  1
Fax: 440.922.3536                               CLEVELAND, OH 44101-4736 

SECTION
B                                         11LF05B
MUNICIPALITY WORKPLACE WAGES WORKPLACE    RESIDENCE TAX
                             TAX WITHHELD WITHHELD

             DRAFT 

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