Form 10A – Fill Out and Use This PDF

Enter Your social security number, Tax year of claim, Your first name and middle initial, Last name, Current home address (number and street), Apt # and City, state, and ZIP code.

Enter your Contact phone number.

Check the Box that applies. A separate Form 10A is 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 the claim.

1. Age Exemption. Enter the Date of Birth (MM/DD/YYYY). 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 attach a copy of your pay stub for the pay period in which your birthday fell.

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 for Days Worked Out of RITA on page 3. You must also complete the Employer Representative section 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 for Days Worked Out of RITA on page 3. You must also complete the Employer Representative section 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. You must also complete the Employer Representative section on page 2. 5. Employer withheld too much (over-withheld) residence municipality tax. Attach a copy of your W-2 Form. You must also complete the Employer Representative section 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. You must also complete the Employer Representative section on page 2. Indicate the address where you actually worked in the box: Work Location Street Address, City, State and 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. You must also complete the Employer Representative section on page 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 is required. 9. Other (Indicate Reason). Attach W-2 Form and other applicable documentation, and a completed Calculation of Overpayment on page 2. You must also complete the Employer Representative section 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.

Submit one claim per form. Please complete a separate 10A if multiple employers/municipalities exist.

1: Enter the Employer Federal ID # and the Employer Name.

2: Enter the RITA Municipality for which tax was withheld (from W-2, Box 20). RITA cannot refund tax withheld to a Non-RITA municipality. 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 not taxable.

4: Amount of over withholding claimed (Box A-9 on page 2 or Line 10 on page 3).

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.

Provide the social security number of the account to which you want the 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. (checked November 1, 2026)

Complete the Calculation of Overpayment for Refund Claim Reasons 4 or 9. A-1: Total Wages from employee's W-2 Form. A-2: Enter name of municipality for which tax was withheld. A-3: Amount of municipal tax withheld to the municipality indicated on line A-2.

A-4: List the complete address of the municipality where the employee physically performed the work or services: Work location street address and City, State, Zip Code. If the employee did not work within the limits of a municipality, skip lines A-5, A-6 and A-7, and enter -0- on line A-8.

A-5: Enter the amount of municipal taxable wages earned in the municipality indicated on line A-4. A-6: Enter the tax rate of the municipality indicated on line A-4. A-7: Tax due to municipality where employee physically worked. Multiply line A-5 by the tax rate on line A-6.

A-8: If the municipality indicated on line A-4 is a RITA municipality, enter the amount from line A-7; otherwise enter -0-. A-9: Amount of over-withheld tax to be refunded or credited. Subtract line A-8 from line A-3. Enter total on Page 1, line 4. Amounts $10 or less will not be refunded or credited. (checked November 1, 2026)

B. Your Home Address during the Tax Year. Your home address for the period covered by this claim was: Employee's Home Street Address, City, State and Zip.

C. Your Employment Dates for the Tax Year: Date of Hire and Date of Separation. If you are still employed, enter “n/a” as the date of separation.

D. Explanation of Reason for Refund (Optional). Use the box to provide more information on your refund request.

Provide the name and contact information for an Employer Representative. The Employer Representative is a person at your employer who can verify your local withholding, work locations and refund information. RITA may contact the Employer Representative to confirm information reported on this Form 10A. The signature of the Employer Representative is NOT required.

Enter Print Representative's Name, Print Representative's Title, Date, Representative's Phone Number and Business/Company Name.

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.

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