Regional Income Tax Agency 
FORM   Adjusted Employer's Municipal Tax 
   11A Withholding Statement 

1. Name: _______________________________________________                                                                  Fed. ID#: _____________________________

   Address #: _______________ Street: _____________________________________________________________

   City: ______________________________________________                                                                          State: ______      Zip: ______________________

2. Originally Filed
   For the period ______/______/________ to ______/______/________
               MM               DD                 YYYY                         MM               DD                 YYYY

           Municipality       Workplace          Workplace Tax                                                                   Residence Tax                  Total Tax
                              Wages                   Withheld                                                                        Withheld                  Withheld

   ____________________       $___________________      $______________       $_____________                                                          $_______________
   ____________________       $___________________      $______________       $_____________                                                          $_______________
   ____________________       $___________________      $______________       $_____________                                                          $_______________
   ____________________       $___________________      $______________       $_____________                                                          $_______________
                         0.00            0.00                                                                                 0.00                     0.00
        Totals          $__________      _______$                                                                            $______                  $_______

3. Adjusting To

           Municipality       Workplace           Workplace Tax         Residence Tax                                                                           Total Tax
                              Wages                   Withheld                                                                        Withheld                  Withheld

   ____________________       $___________________      $______________       $_____________                                                          $_______________
   ____________________       $___________________      $______________       $_____________                                                          $_______________
   ____________________       $___________________      $______________       $_____________                                                          $_______________
   ____________________       $___________________      $______________       $_____________                                                          $_______________
                         0.00            0.00                                                                                 0.00                     0.00
        Totals          $__________      _______$                                                                            $______                  $_______
                                                                                                                        ▲                      ▲           ▲

                                                                                                                             4. Balance Due               $_____________

                                                                                                                             5. Overpayment               $_____________

                                                                                                                                               Refund

                                                                                                                                               Credit   (Must distribute in Section 7)

                        Reason for Adjusting explanation must be provided for all fields.
                        Examples: If you are adjusting the municipality from what was originally reported, you must provide 
                        the physical address of the adjusted municipality you are reporting in the "Adjusted To" column.
6. Reason for Adjusting     If  you are adjusting wages, provide explanation as to why wages changed from the original reported 
                        amount(s). 
   __________________________________________________________________________________________________                                                                                                                                                                     

   __________________________________________________________________________________________________
   __________________________________________________________________________________________________
   __________________________________________________________________________________________________

7. Distribution of Overpayment                   (From Section 5)

          Municipality Amount                              Distribute Credit to
                                                         Tax Period
   ____________________        $__________________          ______/______/_________
                                                        MM                DD                    YYYY

   ____________________        $__________________          ______/______/_________
                                                        MM                DD                    YYYY
    
   ____________________        $__________________          ______/______/_________
                                                        MM                DD                    YYYY

   ____________________        $__________________          ______/______/_________
                                                        MM                DD                    YYYY

   ____________________        $__________________          ______/______/_________
                                                        MM                DD                    YYYY

   ____________________        $__________________          ______/______/_________
                                                        MM                DD                    YYYY

   ____________________        $__________________          ______/______/_________
                                                        MM                DD                    YYYY

   ____________________        $__________________          ______/______/_________
                                                        MM                DD                    YYYY

8. I HAVE EXAMINED THIS RETURN, AND TO THE BEST OF MY KNOWLEDGE, IT IS CORRECT.

   Print Name  :  _____________________________________ Title: _______________________________

   Signature:  _______________________________  Date: ___________  Phone: ______-______-________

   Remit to: REGIONAL INCOME TAX AGENCY -- P.O. BOX 477900 BROADVIEW HEIGHTS, OH 44147-7900
   Fax: 440.922.3536