SDMS US EPA REGION V COLOR - RESOLUTION - 3 IMAGERY INSERT FORM
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SITE NAME CHEMICAL RECOVERY DOC ID # 147464 DOCUMENT COLOR OR X RESOLUTION VARIATION PRP RMD - CHEMICAL RECOVERY PHASE ENFORCEMENT OPERABLE UNITS LOCATION Box# Folder # Subsection PHASE Remedial Removal Deletion Docket (AR DOCUMENTS ONLY) Original Update # Volume of COMMENT(S)
FOLDER M-32
REGIONAL INCOME TAX AGENCY RECONCILIATION OF RETURNS FORM 17 P.O. BOX 7777 Of Income Tax Withheld (Form 11) INDEPENDENCE, OHIO 44131 With Forms W-2 Submitted Herewith
1. Total Number of Emptdyeas 20 3. Total Income Tax Withheld from compensation during Total Number of W-2 Formt Eiwtoead 20 I9?4>as shown by form 11 for the period: JANUARY ••"100,56 JULY J2 FEBRUARY —JStsIiL 1.23.86 |s 12-03-75 01-3 L- ft) •MARCH > 89.78 •aCPTBHl.C.. ______I Federal Employer APRIL 80 ~Q7 OCTOBER 136.11 3 A 0 4 2 0 a 8 TAXPAYER'S COPY 1/13/76 signeture Preside nt Title ^M, /<>(>./$• 134, // OFFICE USE ONLY P S____..______EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT I S ____.______REGIONAL INCOME TAX AGENCY T S______5755 GRANGER ROAD INDEPENDENCE, OHIO 44131 INSTRUCTIONS ON REVERSE SIDE I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT. THIS FORM MUST BE RETURNED WITH REMITTANCE! MAKE CHECKS PAYABLE TO R.I.T.A. MAIL TO: R.I.T.A. IXE DATE Form 11 P. O. BOX 6600-T 1975 CLEVELAND, OHIO 44101 R.I.T.A. CI7 v WHERE LOCATED MONTHLY RETURN XX QUARTERLY RETURN D LINES 1,2 AND 4 MUST BE COMPLETED £ LU 1. TOTAL WAGES SUBJECT TO _|CC WITHHOLDING TAX f <§ 2. AMOUNT OF TAXES WITHHELD $. 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR $. DO NOT CROSS OUT INCORRECT INFORMATION (EXPLAIN ON BACK OF FORM) 4. BALANCE DUE ANDPAID HEREWITH $. ill.11 •DISTRIBUTE BELOW DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED CODE MUNICIPALITY RATE- AMOUNT CODE MUNICIPALITY RATE* AMOUNT 010 AURORA 485 MAYFIELD VILLAGE 020 AVON 500 MIDDLEBURG HTS 040 BAY VILLAGE 520 MORELAND HILLS 060 BEDFORD 540 NEWBURGH HTS 090 BENTLEYVILLE 550 NORTH OLMSTED 100 BEREA 565 NORTH RIDGEVILLE 130 BRECKSVILLi; 580 OAKWOOD 140 BROADVIEW HTS 590 OLMSTED FALLS 160 BROOKLYN HTS 600 ORANGE 180 CHAGRIN FALLS 650 PEPPER PIKE 210 CLEVELAND HTS 660 REMIIMDERVILLE 250 CUV AHOGA HTS .50% 670 RICHMOND HTS 270 EAST CLEVELAND 720 SEVEN HILLS 277 ELYRIA It $132.15 750 SHAKER HTS 300 FAIRVIEW PARK 752 SHEFFIELD VILLAGE 320 GARFIELD HTS 770 SOUTH EUCLID 370 HIGHLAND HTS 775 STREETSBORO 385 HURON 780 STRONGSVILLE 390 INDEPENDENCE 800 UNIVERSITY HTS 400 LAKE WOOD 810 VALLEY VIEW 440 LYIVDHURST 820 WALTON HILLS 460 MAPLE HTS 840 WESTLAKE 480 MAVFIELD HTS 900 WOODMERE ALL TAX RATES ARE 1% UNLESS OTHERWISE INDICATED. DO NOT ADD CITIES INSTRUCTIONS FOR COMPLETING EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT (FORM 11) FOR R.I.T.A. MUNICIPALITIES It is required that on or before the last day of each month, the taxes withheld in the previous month be paid and Form 11 filed with R.I.T.A. However, if the amount withheld in any one month-tor a.municipality is.less thar>,$jp0,00, the employer may defer the filing of Form 11 and the payment of the amount withheld until the last day of the month following the end of the calendar quarter. Please check the appropriate box on the front of Form 11 to designate whether this is a monthly or quarterly return. 1. Place the amount of total wages, salaries, commissions, etc., subject to withholding tax for R.I.T.A. municipalities on iine 1 of Form 11. 2. Place the amount of municipal taxes withheld for the period on line 2. 3. If you have any adjustments to the municipal taxes you have reported for the previous months of this calendar year, then place those adjustments on line 3 of Form 11. Also print on the back of Form 11 the reason for the adjustments or attach a printed or typewritten letter. 4. Subtract line 3 from line 2 and place that amount on line 4 of Form 11. This is the amount of tax due. List the amount of taxes for each municipality next to the name of the municipality where the taxes are due. " PLEASE MAKE CHECK OR MONEY ORDER PAYABLE TO R.I.T.A. ENCLOSE CHECK OR MONEY ORDER AND ORIGINAL COPY OF FORM 11 IN THE ENCLOSED RETURN ENVELOPE. RETAIN DUPLICATE COPY OF FORM 11 FOR YOUR RECORDS. If you have any questions regarding the completion of this form, please call 398-8400. CHANGES If your mailing address, company name, trade name or R.I.T.A. city where located is incorrect or has changed from that shown on Form 11, enter all changes on the form next to the information that has changed. EXPLANATION OF LINE 3 ADJUSTMENTS: OFFICE USE P S_____ EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT I $ ______REGIONAL INCOME TAX AGENCY T $______5755 GRANGER ROAD INDEPENDENCE, OHIO 44131 INSTRUCTIONS ON REVERSE SIDE I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT. THIS FORM MUST BE RETURNED WITH REMITTANCE MAKE CHECKS PAYABLE TO R.I.T.A. MAIL TO: R.I.T.A. ^•GNATURE TITLE DATE —————— Form 11 P. O. BOX 6600-T 1975 CLEVELAND, OHIO 44101 R.I.T.A. Cl TV WHERE LOCATED MONTHLY RETURN XK QUARTERLY RETURN D LINES 1,2 AND 4 MUST BE COMPLETED _ 1. TOTAL WAGES SUBJECT TO _icr WITHHOLDING TAX $u <§ 2 AMOUNT OF TAXES WITHHELD $. 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR $. DO NOT CROSS OUT INCORRECT INFORMATION (EXPLAIN ON BACK OF FORM) 4. BALANCEDUE AND PAID HEREWITH $. it* 'DISTRIBUTE BELOW DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED CODE MUNICIPALITY RATE* AMOUNT CODE MUNICIPALITY RATE" AMOUNT 010 AURORA 485 MAYFIELD VILLAGE 020 AVON 500 MIDDLEBURG HTS "~ 040 BAY VILLAGE 520 MORELAND HILLS 060 BEDFORD 540 NEWBURGH HTS 090 BEMTLEYVILLE 550 NORTH OLMSTED 100 BE Pi E A 565 NORTH RIDGEVILLE 130 BRECKSVILLE 580 OAKWOOD 140 BROADVIEWHTS 590 OLMSTED FALLS 160 BROOKLYN HTS 600 ORANGE 180 CHAGRIN FALLS ^650 PEPPER PIKE 210 CLEVELAND HTS 660 REMINDERVILLE 250 CUYAHOGA HTS .50% 670 RICHMOND HTS 270 EAST CLEVELAND 720 SEVEN HILLS 277 ELYRIA 11 $113.46 750 SHAKER HTS 300 ...FAIRVIEWPAflK 752 SHEFFIELD VIJ.LAGE 320 GARFIELD HTS 770 SOUTH EUCLID 370 HIGHLAND HTS 775 STREETSBORO 385 HURON 780 STRONGSVILLE 390 INDEPENDENCE 800 UNIVERSITY HTS 400 LAKEWOOD 810 VALLEY VIEW 440 LYNDHURST 820 WALTON HILLS 460 MAPLE HTS 840 WESTLAKE 480 MAYFIELD HTS 900 WOODMERE ' ALL TAX RATES ARI- 1 % UNLESS OTHERWISE INDICATED. DO NOT ADD CITIES OFFICE USE ONLY P S___..__.._._ EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT REGIONAL INCOME TAX AGENCY T $ ______. 5755 GRANGER ROAD INDEPENDENCE, OHIO 44131 INSTRUCTIONS ON REVERSE SIDE I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT | THIS FORM MUST BE RETURNED WITH REMITTANCE MAKE CHECKS PAYABLE TO R.I.T.A. MAIL TO: R.I.T.A. SIGNATURE 5 TITLE DATE Form 11 F P. O. BOX 6600-T 1975 CLEVELAND, OHIO 44101 R.I.T.A. CITY WHERE. LOCATED MONTHL Y RETURN X QUARTERL Y RETURN a LINES 1,2 AND 4 MUST BE COMPLETED ig 1 TOTAL WAGES SUBJECT TO WITHHOLDING TAX $—13 2. AMOUNT OF TAXES WITHHELD S. 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR $. DO NOT CROSS OUT INCORRECT INFORMATION (EXPLAIN ON BACK OF FORM) 4. BALANCEDUE AND PAID HEREWITH $. lift.11 'DISTRIBUTE BELOW * DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED CODE MUNICIPALITY RATE* AMOUNT CODE MUNICIPALITY RATE* AMOUNT 010 AURORA 485 MAYFIELD VILLAGE 020 AVON 500 MIDDLEBURG HfS 040 BAY VILLAGE 520 MORELAND HILLS 060 BEDFORD 540 NEWBURGH HTS 090 BENTLEYVILLE 550 NORTH OLMSTED 100 BEREA 565 NORTH RIDGEVILLE 130 BRECKSVILLE 580 OAKWOOD 140 BROADVIEW HTS 590 OLMSTED FALLS 160 BROOKLYN HTS 600 ORANGE 180 CHAGRIN FALLS 650 PEPPER PIKE 210 CLEVELAND HTS 660 REMINDERVILLE 250 CUYAHOGA HTS .50% 670 RICHMOND HTS 270 EAST CLEVELAND 720 SEVEN HILLS 277 ELYRIA 750 SHAKER HTS ft $136-11 300 FAIRVIEWPARK 752 SHEFFIELD VILLAGE "320 GARFIELDHTS 770 SOUTH EUCLID 370 HIGH LAND HTS 775 STREETSBORO 385 HURON 780 STRONGSVILLE 390 INDEPENDENCE 800 UNIVERSITY HTS 400 LAKE WOOD 810 VALLEY VIEW 440 LYNDHURST 820 WALTON HILLS 460 MAPLE HTS 840 j WESTLAKE 480 MAVFIELD HTS 900 WOODMERE ALL TAX RATES ARE 1% UNLESS OTHERWISE INDICATED. DO NOT ADD CITIES OFFICE I'SE ONLY p :; ___ __.__ EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT I H ____. ___.___ REGIONAL INCOME TAX AGENCY T S______5755 GRANGER ROAD INDEPENDENCE, OHIO 44131 INSTRUCTIONS ON REVERSE SIDE I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT. [THIS FORM MUST BE RETURNED WITH REMITTANCE] MAKE CHECKS PAYABLE TO R.i.T.A. President 10-20-75 MAIL TO: R.I.T.A. SIGNATURE TITLE DATE ——————— Form 11 P. O. BOX 6600-T i97s CLEVELAND, OHIO 44101 R.I.T.A. CH V WHERE LOCATED MONTHLY RETURN [XX QUARTERLY RETURN D LINES 1,2 AND 4 MUST BE COMPLETED 1 TOTAL WAGES SUBJECT TO WITHHOLDING TAX .t 10,497.60 2. AMOUNT OF TAXES WITHHELD $. 104.96 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR $. DO NOT CROSS OUT INCORRECT INFORMATION (EXPLAIN ON BACK OF FORM) 4. BALANCE DUE ANDPAID HEREWITH $. 104,96 "DISTRIBUTE BELOW * DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED CODE MUNICIPALITY RATE* AMOUNT CODE MUNICIPALITY RATE* AMOUNT 010 AURORA 485 MAYFIELD VILLAGE 020 AVON 500 MIDDLEBURG HTS 040 BAY VILLAGE 520 MORELAND HILLS 060 BEDFORD 540 NEWBURGH HTS 090 8ENTLEYVILLE 550 NORTH OLMSTED 100 BEREA 565 NORTH RIDGEVILLE 130 BRECKSVILLE 580 OAKWOOD 140 BROADVIEWHTS 590 OLMSTED FALLS 160 BROOKLYN HTS 600 ORANGE 180 CHAGRIN FALLS 650 PEPPER PIKE 210 CLEVELAND HTS 660 REMINDERVILLE 250 CUYAHOGA HTS .50% 670 RICHMOND HTS 270 EAST CLEVELAND 720 SEVEN HILLS 277 ELYRIA 1% $104.96 750 SHAKER HTS 300 FAIRVIEWPARK 752 SHEFFIELD VILLAGE 320 GARFIELD HTS 7/0 SOUTH EUCLID 370 HIGHLAND HTS 775 STREETSBORO 385 HURON 780 STRONGSVILLE 390 INDEPENDENCE 800 UNIVERSITY HTS 400 LAKEWOOD 810 VALLEY VIEW 440 LYNDHURST 820 WALTON HILLS 460 MAPLE HTS 840 WESTLAKE 480 MAYFIELD HTS 900 WOODMERE ALL TAX RATES ARE 1% UNLESS OTHERWISE INDICATED. DO NOT ADD CITIES OFFICE JSE P $ ______EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT I $ ______REGIONAL INCOME TAX AGENCY T $______5755 GRANGER ROAD INDEPENDENCE, OHIO 44131 INSTRUCTIONS ON REVERSE SIDE I HAVE EXAMINED THIS RETURN AND TO THE BF.ST OF MY KNOWLEDGE IT IS CORRECT. [THIS FORM MUST BE RETURNED WITH REMITTANCE MAKE CHECKS PAYABLE TO R.I.T.A. MAILTO: R.I.T.A. SIGNATURE —————— Form 11 P. O. BOX 6600-T 1975 CLEVELAND, OHIO 44101 R.I.T.A. Ci "Y WHERE. LOCATED MON THL Y RE TURN J_f QUAR TERL Y RETURN D , LINES 1,2 AND 4 MUST BE COMPLETED 2 w 1. TOTAL WAGES SUBJECT TO -JtC WITHHOLDING TAX <§ 2. AMOUNT OF TAXES WITHHELD 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR DO NOT CROSS OUT INCORRECT INFORMATION (EXPLAIN ON BACK OF FORM) 4. BALANCE DUE AND PAID HEREWITH S. •DISTRIBUTE BELOW * DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED CODE MUNICIPALITY RATE- AMOUNT CODE MUNICIPALITY RATE* AMOUNT 010 AURORA 485 MAYFIELD VILLAGE 020 AVON 500 MIDDLEBURG HTS 040 BAY VILLAGE 520 MORELAND HILLS 060 BEDFORD 540 NEWBURGH HTS 090 BEMTLEYVILLE 550 NORTH OLMSTED 100 BEREA 565 NORTH RIDGEVILLE 130' BRECKSVILLE 580 OAKWOOD 140 BROADVIEW NTS 590 OLMSTED FALLS 160. BROOKLYN HTS 600 ORANGE 180 CHAGRIN FALLS 650 PEPPER PIKE 210, CLEVELAND HTS 660 REMINDEHVILLE 250' CUYAHOGA HTS .50% 670 RICHMOND HTS 270 EAST CLEVELAND 720 SEVEN HILLS 277 ELVRIA 11 $liS.M 750 SHAKER HTS •300 FAIHVIEWPARK 752 SHEFFIELD VILLAGE 320 GARFIELD HTS 770 SOUTH EUCLID 370 HIGHLAND HTS 775 STREETSBORO 385 HURON 780 STRONGSVILLE 390 INDEPENDENCE 800 UNIVERSITY HTS 400 LAKEWOOD 810 VALLEY VIEW 440 LYMDHURST 820 WALTON HILLS 460 MAPLE HTS 840 WESTLAKE 430 MAYFIELD HTS 900 WOODMERE ALL TAX RATES ARF 1% UNLESS OTHERWISE INDICATED. DO NOT ADD CITIES OFFICE USE P $______EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT I S ___.___ REGIONAL INCOME TAX AGENCY T $ _____ 5755 GRANGER ROAD INDEPENDENCE, OHIO 44131 INSTRUCTIONS ON REVERSE SIDE MIMED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT. . THIS FORM MUST BE RETURNED WITH REMITTANCE MAKE CHECKS PAYABLE TO R.I.T.A. MAJL TO: R.I.T.A. DATE Form 11 P. O. BOX 6600-T 1975 IDENTIFICATION NO. CLEVELAND, OHIO 44101 R.I.T.A. CITY WHERE LOCATED MONTHLY RETURN 8 QUARTERLY RETURN D LINES 1, 2 AND 4 MUST BE COMPLETED . £ UJ 1. TOTAL WAGES SUBJECT TO _Jtt WITHHOLDING TAX <§ 2. AMOUNT OF TAXES WITHHELD $ 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR $. DO NOT CROSS OUT INCORRECT INFORMATION (EXPLAIN ON BACK OF FORM! 4. BALANCE DUE ANDPAID HEREWITH $. 01. Qi •DISTRIBUTE BELOW DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED \ CODE MUNICIPALITY RATE* AMOUNT CODE MUNICIPALITY RATE- AMOUNT 010 AURORA 485 MAYFIELD VILLAGE 020 AVON 500 MIDDLEBURG HTS 040 BAY VILLAGE 520 MORELAND HILLS 060 BEDFORD 540 NEWBURGH HTS 090 BENTLEYVILLE 550 NORTH OLMSTED 100 BEREA 565 NORTH RIDGEVILLE 130 BRECKSVILLE 580 OAKWOOD 140 BROADVIEW HTS ,590 OLMSTED FALLS 160 BROOKLYN HTS 600 ORANGE 180 CHAGRIN FALLS 650 PEPPER PIKE 210 CLEVELAND HTS 660 REMINDERVILLE 250 CUYAHOGA HTS .50% 670 RICHMOND HTS 270 EAST CLEVELAND 720 SEVEN HILLS 277 ELYRIA n $!*S-9S 750 SHAKER HTS 300 FAIRVIEW PARK 752 SHEFFIELD VILLAGE 320 GARFIELD HTS 770 SOUTH EUCLID 370 HIGHLAND HTS 775 STREETSBORO 385 HURON 780 STRONGSVILLE 390 INDEPENDENCE ——— 800 UNIVERSITY HTS 400 LAKE WOOD 810 VALLEY VIEW 440 LYMDHURST 820 WALTON HILLS 460 MAPLE HTS 840 WESTLAKE ' 480 MAYFIELD HTS 900 WOODMERE ALL TAX RATES ARE 1% UNLESS OTHERWISE INDICATED. DO NOT ADD CITIES OFFICE USE OMLY P S . .._ EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT REGIONAL INCOME TAX AGENCY 5755 GRANGER ROAD INDEPENDENCE, OHIO 44131 INSTRUCTIONS ON REVERSE SIDE I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT. [THIS FORM MUST BE RETURNED WITH REMITTANCE MAKE CHECKS PAYABLE TO R.I.T.A. MAIL TO: R.I.T.A. SIGNATURE TITLE DATE ——————— Form 11 P. 0. BOX 6600-T 1975 CLEVELAND, OHIO 44101 R.I.T.A. Cl : Y WHERE LOCATED MONTHLY RETURN [j; QUARTERLY RETURN D LINES 1, 2 AND 4 MUST BE COMPLETED ill 1. TOTAL WAGES SUBJECT TO _|DC WITHHOLDING TAX $__C <§ 5 < 2. AMOUNT OF TAXES WITHHELD 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR DO NOT CROSS OUT INCORRECT INFORMATION (EXPLAIN ON BACK OF FOFtM) 4 BALANCE DUE AND PAID HEREWITH '-BIST RI BUTE BELOW * DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED CODE MUNICIPALITY RATE* AMOUNT CODE MUNICIPALITY RATE" AMOUNT 010 AURORA 485 MAYFIELD VILLAGE 020 AVON 500 MIDDLEBURG HTS 040 BAY VILLAGE 520 MORELAND HILLS 060 BEDFORD 540 NEWBURGH HTS 090 BENTLEYVILLE 550 NORTH OLMSTED 100 BEREA 565 NORTH RIDGEVILLE 130 BRECKSVILLF. 580 OAKWOOD 140 BROADVIEW HTS 590 OLMSTED FALLS 160 BROOKLYN HTS 600 ORANGE 180 CHAGRIN FALLS 650 PEPPER PIKE 210 CLFVELAND HTS 660 REMINDERVILLE 250 CUYAHOGA HTS .50% 670 RICHMOND HTS 770 EAST CLEVELAND 720 SEVEN HILLS 277 ' ELYRIA 750 SHAKER HTS i% 92.08 300 • FAI.'t VIEW PARK 752 SHEFFIELD VILLAGE 320 GAB FIELD HTS 770 SOUTH EUCLID 370 HIGHLAND HTS ,775 STREETSBORO 385 HURON 780 STRONGSVILLE 390 INDEPENDENCE 800 UNIVERSITY HTS 400 LAKE WOOD 810 VALLEY VIEW 440 LYNDHURST 820 WALTON HILLS 460 MAPLE HTS 840 WESTLAKE 480 MAYFIELD HTS 900 WOODMERE ALL TAX RATES ARE 1% UNLESS OTHERWISE INDICATED. DO NOT ADD CITIES OFFICE USE ONLV P $______EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT I S. REGIONAL INCOME TAX AGENCY T $. 5755 GRANGER ROAD INDEPENDENCE, OHIO 44131 HAVE EXAMINED THIS RETURN AND TO THE Bt:ST OF MY KNOWLEDGE IT IS CORRECT. INSTRUCTIONS ON REVERSE SIDE [THIS FORM MUST BE RETURNED WITH REMITTANCE MAKE CHECKS PAYABLE TO R.I.T.A. Jim- President—— 6^g7/76 MAIL TO: R.I.T.A. SIGNATURE TT D Form 11 FEDERAL EWPLOVtR P. O. BOX 6600-T 1975 IDENTIFICATION NO CLEVELAND, OHIO 44101 R.I.T.A. CI'Y WHERE LOCATED MONTHLY RETURN Qr QUARTERLY RETURN D LINES 1,2 AND 4 MUST BE COMPLETED £ UJ 1. TOTAL WAGES SUBJECT TO _jtr WITHHOLDING TAX IP.612.40 2. AMOUNT OF TAXES WITHHELD $ ——106.15 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR $. DO NOT CROSS OUT INCORRECT INFORMATION (EXPLAIN ON BACK OF FORM) 4. BALANCE DUE ANDPAID HEREWITH S. 106.15 •DISTRIBUTE BELOW * DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED CODE MUNICIPALITY RATE* AMOUNT CODE MUNICIPALITY RATE* AMOUNT 010 AURORA 485 MAYFIELD VILLAGE 020 AVON 500 MIDDLEBURG HTS 040 BAY VILLAGE ina. "wrwft.'uWNfiyiVi'L.'L.'cj 060 BEDFORD 540 NEWBURGH HTS 090 BENTLEYVILLE 550 NORTH OLMSTED 100 BEREA 565 NORTH RIDGEVILLE 130 BRECKSVILLE 580 OAKWOOD 140 BROADVIEW HTS 590 OLMSTED FALLS 160 BROOKLYN HTS 600 ORANGE 180 CHAGRIN FALLS 650 PEPPER PIKE 210 CLEVELAND HTS 660 REMINDERVILLE 250 CUYAHOGA HTS .50% 670 RICHMOND HTS 270 EAST CLEVELAND 720 SEVEN HILLS 277 ELYRIA 750 SHAKER HTS 1% — 106.15 300 FAIRVIEWPARK 752 SHEFFIELD VILLAGE 320 GARFfELD-HTS 770 SOUTH' EUCLID - 370 HIGHLAND HTS 775 STREETSBORO 385 HURON 780 STRONGSVILLE 390 INDEPENDENCE 800 UNIVERSITY HTS 400 LAK.EWOOD 810 VALLEY VIEW 440 LYIVDHURST 820 WALTON HILLS 460 MAFLE HTS 840 WESTLAKE 480 MAYFIELD HTS 900 WOODMERE * ALL TAX RAT6S ARE 1 % UNLESS OTHERWISE INDICATED. DO NOT ADD CITIES OFF'CE 'JSE ONLY P $ ____.______EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT i s____._:__ REGIONAL INCOME TAX AGENCY T S___L-.___.__L. 5755 GRANGER ROAD INDEPENDENCE, OHIO 44131 INSTRUCTIONS ON |SE SIDE I HAVE EXAMINED THIS RETURN AND TO THE BCST OF MY KNOWLEDGE IT IS CORRECT. [THIS FORM MUST BE RETURNEP|ifTH REMITTANCE MAKE CHECK$ PAYAB$$lb R.i.T.A. MAIL TO: R.I.T.A. ; **"J SIGNATURE —._,———«—— .. ; : v. Form 11 fEDERAL EMPLOYER V p. o. BOX eeciSt 1975 IDENTIFICATION NO , CLEVELAND^QfHIO 44101 R.I.T.A. CITY WHERt LOCATED MONTHLY RETURN ^ Quk^jRLY RETURN Q "f'ls' LINES 1, ?f AND 4 MUST* PLETED LU 1. TOTAL WAGES SUBJECT TO j MUNICIPAL TAXES WITHHELD BASEDON CITY WHERf WORK PERFORMED 'CODE MUNICIPALIT.V; AMOUNT CODE MUNICIPALITY AMOUNT .• '. -:. $> 010 AURORA" ' '" *•'"•• •"•'! ;" ' • 485 MAYPI-ELD VILLAGE • •-• —— rrff ——— 020 AVON ••>."', ".';••'••.• 500 P^QJL€BUBG;;HTS :;,-. 040 BAY VILLAGE '' ,' ;-..; • 520 i^'ft-lLAfc HILLS ' '} ; , 060 BEDFORD 1 . .V , 540 iE'WBU^GH HTS S , ' : '• 090 BENTLEYVILLE . .. ; 550 fTORTH OLMSTED .,;: : 100 BEREA L' .•.t>", ,," . ',,' . './'•-. • • ,, 565 WCJRTH^RIPGEVILLt^ ^ .1 130 BRC.CKSVILLE ••' .,; . .V... '; 580 OAK WOOD ' • . .: j; 1 140 BROADVIEW HTS V ^ .,'.";.' 590 OLMSTED FALLS '160 BROOKLYN HTS i!.: 600 ORAN'GE —— ~Hi —— 1180 CHAGRIN FALLS '? ' 650 PEPPER PIKE ———+y —— 660 '.210 CLEVELAND HTS " j REMINDERVILLE j'-i ,.- E50 CUV.AHOGA HTS ' '"T .50% 670 RICHMOND HTS '•'i: 270 EAST CLEVELAND '.'' 720 SEVEN HILLS 277 ELYRIA 750 SHAKER HTS i i • 4~ _Ut —— 89 07 > •:: •__. ,.| 3'tJO FAIRVIEWPARK , 752 SHEFFIELD. VILLAGE " ' f: 3?0 GARFIELD HTS : ' :V ". ' 770 SOUTH EUCLID ; - • - ''• ': 3|0_ HIGHLAND HTS "" "\'""- ' 775 STREETSBORO ' ' ""'"N : :iks HURON " 780 STRONGSVILLE 390 INDEPENDENCE -• 800 UNIVERSITY HTS 40b LAKEWOOD ',.!/'; ^fe'--'' 810 VALLEY VIEW 1 449 LY^DHURST "^: '" 820 WALTON HILLS ,:?• !- " s- • -.;• • , - •• - ^ 460 MAPLE HTS ' ' ' . . 840 *" WESTLAKE • i-'-ti, 48q MAVFIELDHTS * 900 WOODMERE Lp '"• : ft •• '•', • • • '' riil ALL TAX RATES ARE 1%.,UNLESS OTHERWISE INDICATED. DO NOT ADD CITIES \*.& & p s. EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT I $. REGIONAL INCOME TAX AGENCY T $. 5755 GRANGER ROAD INDEPENDENCE, OHIO 44131 INSTRUCTIONS ON REVERSE SIDE I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT. [THIS FORM MUST BE RETURNED WITH REMITTANCE MAKE CHECKS PAYABLE TO R.I.T.A. MAIL TO: R.I.T.A. ——————— Form 11 P. O. BOX 6600-T 1975 CLEVELAND, OHIO 44101 R.I.T.A. CITY WHERE LOCATED MONTHLY RETURN M ' QUARTERLY RETURN H LINES 1, 2 AND 4 MUST BE COMPLETED Z UJ 1. TOTAL WAGES SUBJECT TO _|DC WITHHOLDING TAX $ 6,976.46 1. AMOUNT OF TAXES WITHHELD $. 39.76 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR $. DO NOT CROSS OUT I INCORRECT INFORMATION (EXPLAIN ON BACK OF FORM) 4. BALANCE DUE ANDPAID HEREWITH S. "DISTRIBUTE BELOW 99.70 * DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED CODE MUNICIPALITY RATE" AMOUNT CODE MUNICIPALITY RATE* AMOUNT 010 AURORA 485 MAYFIELD VILLAGE 020 AVON 500 MIDDLEBURG HTS 040 BAY VILLAGE 520 MORELAND HILLS 060 BEDFORD 540 NEWBURGH HTS 090 BENTLEYVILLE 550 NORTH OLMSTED 100 BEREA 565 NORTH RIDGEVILLE 130 BRE.CKSVILLE 580 OAKWOOD 140 BROADVIEW HTS 590 OLMSTED FALLS 160 BROOKLYN HTS 600 ORANGE 180 CHAGRIN FALLS 650 PEPPER PIKE 210 CLEVELAND HTS 660 r REMINDERVILLE 250 CUYAHOGA KTS .50% 670 RICHMOND HTS 270 EAST CLEVELAND 720 SEVEN HILLS 277 ELVRIA 750 SHAKER HTS 1% $m.7a 300 FAIRVIEWPARK 752 SHEFFIELD VILLAGE 320 GAPFIELD HTS 770 SOUTH EUCLID 370 HIGHLAND HTS 775 STREETSBORO 385 HURON 780 STRONGSVILLE INDEPENDENCE 800 UNIVERSITY HTS 390 —————————— 400 LAKEWOOD 810 VALLEY VIEW 440 LYNDHURST 820 WALTON HILLS 460 MAPLE HTS 840 WESTLAKE 480 MAY FIELD HTS 900 WOODMERE i • ALL FAX RATES ARE 1% UNLESS OTHERWISE INDICATED. DO NOT ADD CITIES EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT .'.:.,, REGIONAL INCOME TAX AGENCY ;r s_ ._-.._...„.._.. 5755 GRANGER ROAD INDEPENDENCE, OHIO 44131 1 HAVF F • AMINED 'i AND TO'THEBFST OF MY KNOWLEDGE IT is CORRECT __..__INSTRUCTIONS ON fi|VERSE SIDE ITHIS FORMMUSTBERETlffl LINES 1,2 AND 4 M@^K COMPLETED 1. TOTAL WAGES SUBitECT TO;-:':?' '^a. A ? WITHHOLDING TAX .-j s 8t871.84 AMOUNT OF TAXES 3. ADJUSTMENTS FOR PRE.V). jLL CHANGfS ABOVE MONTHS OF CALENDAR Y;I UT iiMCt»Rf|£CT INFORMATION (EXPLAIN ilNt'.BACK OF FO 4. BALANCE DUE AND PAID M, OF EMPLOYER'S MUWii. TAXES WITHHELD ON CITY WHeflE WOR K PER FORMED ' , ,, ,• ;" RA.TE*. AMOUNT CODE ' -MUNICIPALITY AMOUNT '•••!J'-i:'tif.itJ :: .ft---.;'?.. '• .:!:-!>' ' ' : ; ; 010 AUROR ^ffpjjfei:; i" - ' • f j :„ 48£i. MAYFIELD VILLAGE .- ^ • ''•'. ^,lj ,' „ .. M In (.., f.rn, I'M. j . .i'ii ... 020 AVON i*i^^pc .f • ' , iiOU MSDDLciBUF^G HTS "', ;^ •IJI *; ': ' .s^JBJptei£...~..~ ...-...-..-4 •' , •" • .' (.' • •' 040 BAY VILLAGE • Vt '•••• " •' !•; H:?O uMOF-it LAND HILLS . , ,!••'•;'.? 060 BEDFORD r *'. :.:••''.•' ;• • ' I ''' T~ b4(). NEW BURGH HTS j ' . . , ,.,' ^ fck '''''**>••' ' b- 090 550 .MQRTij OuMSTED^ ',. _ • -.:'ii|lr jjF.-jjLj^Yva.il ;, ••;:'' t • '*' lit-'?/' . .' j J.Jlg^lte^;; . ';;,-,;.: 565. fir-" ';;• 10 160 8FI-:)OK:.YM ^sSftv-.'" ''•' '••:' •V RQO; CHANGE . • ...,, I, ...... 1 1 1 .,,.«..__.__..... 1 ...... M ~sa ^l*^gt; 6hO. ..PEfPER PlfCE ," 210 •Hfp'^i-i-" . r fii.O REMINDEHVILLE H 2!50 :"ftiJgv':.' . ~" .50^ ——— |" GV'C r-iiCHMijwi i HTP ,: ;,.- 270 EA. T Oi rV.E! ^S'S't''..A( Taol SEVLM HILLS , • § -;..;.' !: IZL77 El. RIA :?^slf ;:• ' i* $89 72 71,0, SHAKER HTS . _ „ ,. •;!•; 7t 300 '. * ^ i. .'JMrMTIELO ViLLAGE . ., ,..( "320 rfe^fe;'""' " " "" ~" " 1' ...... '...... 1 7 /I! SOU : H r L?LLI U ,!, ,. HIC.HLAMD fl^^i^;-. f .STRFFTSBORO '; ; '||- |A:V. --: ;: ^^fefefc ' -• ?{-•.(•• M '!i(\i.;sviLL.t- ..•'-.: .,•/: '. 390 INI: HP ('pfel^'' 81 '0 I.H\; • ! fiSI FY HTS : ': 400 LA: Ewoon ''•^SP^""- /; '••• 81 (r .VAI.'..hY V ifiW -'^'^?$£•'-;•. 440 L\ < 'DHURS"r"!^^PV: : ' ' R?(> WAL TON HILI S ''' !^,\ ^•/ • 1 1 : 460 ' '"'•f^i-"' \*'"'. ' " W' • 840 WESTI.AKF '••.':• , 480 ; 900 WOODMEBE •':;-; '^Sl^fSS1i ' i • .-iij 'SpS' ___ ., ' ' /'''••' ''Vif •' ,% UNLESS DT'HERWiSE IMOICATEO1. DO NOT ADD CITIES >•*!•: \ .^x ^ $ OFFICE 'JSF P $_____ EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT i $______REGIONAL INCOME TAX AGENCY T $___.__ 5755 GRANGER ROAD INDEPENDENCE, OHIO 44131 INSTRUCTIONS ON REVERSE SIDE I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT. [THIS FORM MUST BE RETURNED WITH REMITTANCE MAKE CHECKS PAYABLE TO R.I.T.A. 2-25-rTS MAIL TO: R.I.T.A. SIGNATURE DATE —————— Form 11 P. O. BOX 6600-T 1975 CLEVELAND, OHIO 44101 R.I.T.A. C: FY WHERE LOCATED MONTHLY RETURN [£ QUARTERLY RETURN C LINES 1,2 AND 4 MUST BE COMPLETED 1. TOTAL WAGES SUBJECT TO WITHHOLDING TAX $ 10,053.06 2. AMOUNT OF TAXES WITHHELD $——100.56 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR $. DO NOT CROSS OUT INCORRECT INFORMATION (EXPLAIN ON BACK OF FORM) 4. BALANCEDUE AND PAID HEREWITH $. "DISTRIBUTE BELOW 100.56 DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED CODE MUNICIPALITY RATE" AMOUNT CODE MUNICIPALITY RATE" AMOUNT 010 AURORA 485 MAYFIELD VILLAGE 020 AVON 500 MIDDLEBURG HTS 040 BAY VILLAGE 520 MORELAND HILLS 060 BEDFORD 540 NEWBURGH HTS 090 BENTLEYVILLE 550 NORTH OLMSTED 100 BEREA 565 NORTH RIDGEVILLE 130 BRECKSVILLE 580 OAKWOOD 140 BROADVIE\A HTS 590 OLMSTED FALLS 160 BROOKLYN HTS 600 ORANGE 180 CHAGRIN FALLS 650 PEPPER PIKE 210 CLEVELAND HTS 660 REMINDERVILLE 250 CUYAHOGA HTS .50% 670 RICHMOND HTS 270 EAST CLEVELAND 720 SEVEN HILLS 750 SHAKER HTS 277 ELYRIA 1% $100.56 300 FAIRVIEW PARK 752 SHEFFIELD VILLAGE 320 GARFIFLD f-TS 770 SOUTH EUCLID 370 HIGH-LAND HTS 775 STRhETSBORO , 385 HLRON 780 STRONGSVILLE 390 INDEPENDENCE 800 UNIVERSITY HTS 400 LAKEWOOD 810 VALLEY VIEW 440 LYNDHURST 820 WALTON HILLS —————————— 460 MAPLE HTS 840 WESTLAKE 480 MAYFIELD HTS 900 WOODMERE —————————— * ALL TAX RATES ARE 1% UNLESS OTHERWISE INDICATED. DO NOT ADD CITIES >l: OFFICE USE ONLY P 5______EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT I S______REGIONAL INCOME TAX AGENCY T S______5805 VALLEY BELT ROAD INDEPENDENCE, OHIO 44131 INSTRUCTIONS ON REVERSE SIDE i HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT. THIS FORM MUST BE RETURNED WITH REMITTANCE MAKE CHECKS PAYABLE TO R.I.T.A. MAIL TO: R.I.T.A. DATE ——————— Form 11 P. 0. BOX 6600-T 1974 PERIOD ENDING DATE CLEVELAND, OHIO 44101 R.I.T.A. CITY WHERE LOCATED MONTHLY RETURN D QUARTERLY RETURN # LINES 1, 2 AND 4 MUST BE COMPLETED is 1. TOTAL WAGES SUBJECT TO WITHHOLDING TAX 2. AMOUNT OF TAXES WITHHELD $. 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR $. (EXPLAIN ON BACK OF FORM) DO NOT CROSS OUT INCORRECT INFORMATION 4. BALANCE DUE AND PAID HEREWITH $. ALL MUNICIPALITIES LISTED BELOW HAVE A TAX RATE OF 1% 'DISTRIBUTE BELOW EXCEPT CUYAHOGA HTS WHICH HAS A TAX RATE OF %%. *DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT 010 AURORA $ 250 CUYAHOGA HTS $ 500 MIDDLEBURG HTS $ 720 SEVEN HILLS $ 040 BAY VILLAGE 277 ELYRIA 520 MORELAND HILLS 750 SHAKER HTS tl#U$ SHEFFIELD 060 BEDFORD 300 FAIRVIEWPARK 540 NEWBURGH HTS 752 VILLAGE 090 BENTLEYVILLE 320 GARFIELDHTS 550 NORTH OLMSTED 770 SOUTH EUCLID 100 BEREA 370 HIGHLAND HTS 565 NORTH RIDGEVILLE 775 STREETSBORO 130 BRECKSVILLE 390 INDEPENDENCE 580 OAKWOOD 780 STRONGSVILLE 140 BROADVIEWHTS 400 LAKEWOOD 590 OLMSTED FALLSf L , 800 UNIVERSITY HTS 160 BROOKLYN HTS 440 LYNDHURST 600 ORANGE ^ V^VP . 810 VALLEY VIEW ) 180 CHAGRIN FALLS 460 MAPLE HTS 650 PEPPER PIKE •J620 WALTON HILLS 210 CLEVELAND HTS 480 MAYFIELDHTS 660 REMINDERVILLE ^tf7 n • I jaqaMt* jafeida* i«Jap»j JRQ •jflfl«lpi»oM fpjooaa JM>! «6oaqo ••! *ta«iiJts Ai«A099t i«0|awt3 ot Xwidawo t««f"»10 8 Xoadnoo «f^i jo «wa« aq? pae^qo a«af am ^aq» nef rjoim 09 it *f€ Return This Form And All City Copy W-2's TO: •*• REGIONALINCOMETAXAGENCYRECONCILIATIONOFRETURNS.FORM17 P.O. BOX7777OfIncomeTaxWithheld(Form11) INDEPENDENCE, OHIO44131WithFormsW-2SubmittedHerewit Federal Employe) Identification No, STATEMENT DATE 2. TotalRITAWagesPaid12^..18%.1 1. TotalNumberofEmployees2// Total NumberofW—2FormsEnclosed^ TAXPAYER'S COPY . |DUEDAT)-, c &''-f''f-t 1*^3/^/s$fapfji4L/Ge.n-fngji.1/22/7\ J •JUNE *2&&*~J1'DECEMBERS33^'®5 •MARCH *-275^"SEPTEMBERS3///Q 3. TotalIncomeTaxWithheldfromcompensationduring 4. Thistotalshouldequa1% *lf cuarterlypaymentswiji'errsade,monthlbreakdownnot APRIL OCTOBER MAY NOVEMBER FEBRUARY AUGUST required- Explainfullyandiscrepancobackfthisform. 1974 asshownbyform1fortheperiod: Signature Titl«Din i * • -Cx C71 OFFICE USE ONLY P $______EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT I $______REGIONAL mCWHE TAX AGENCY T $______5806 VALLEY BtLT ROAD tMDmNDtMCE. OHIO 44131 INSTRUCTIONS ON I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT. THIS FORM MUST BE WHWTTAWCEl MAKE CHECKS PAYABLE MAIL TO: ft.i.TJL SIGNATURE TITLE DATE Form 1 1 P. O. BOX 6600 T PERIOD ENDING 1974 CLEVELAND, OHIO 44101 R.I.T.A. CITY WHERE LOCATED MONTHLY RETURN D D Federal Employer 1 M I I I I Identification No Company Name LINES 1, 2 AND 4 MUST BE COMPLETED and street, including apartment number, or rural route) Present Address (Number 1. TOTAL WAGES SUBJECT TO WITHHOLDING TAX $ ———————— O R TYP E City, tovvn or post office. State and ZIP Code MAILIN G ADDRES S 2. AMOUNT OF TAXES WITHHELD $______PLEAS E PRIN T 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR $ ______(EXPLAIN ON BACK OF FORM) DO NOT CROSS OUT INCORRECT INFORMATION 4. BALANCE DUE AN DPA 010 AURORA $ 277 ELYRIA $ 500 MIDDLEBURG HTS $ 720 SEVEN HILLS $ oso AVON 300 FAIRVI6WPARK 520 MORELAND HILLS 750 SHAKER HTS SHEFFIELD 040 BAY VILLAGE 320 GARFIELD HTS 540 NEWBURGH HTS 752 VILLAGE 060 BEDFORD 370 HIGHLAND HTS 550 NORTH OLMSTED 770 SOUTH EUCLID 090 BENTLEYVILLE 385 HURON 565 NOriTH RIDGEVILLE 775 STREETSBORO 100 BEREA 390 INDEPENDENCE 580 OAKWOOD 780 STRONGSVILLE 130 BRECKSVILLE 400 LAKEWOOD 590 OLMSTED FALLS 800 UNIVERSITY HTS 140 BROADVIEWHTS 440 LYNDHURST 600 ORANGE 810 VALLEY VIEW 160 BROOKLYN HTS 460 MAPLE HTS 650 PEPPER PIKE 820 WALTON HILLS CHAGRIN FALLS 180 480 MAYFIELDHTS 660 REMINDERVILLE 840 WESTLAKE MAVFIELD 210 CLEVELAND HTS 485 670 VILLAGE RICHMOND HTS 900 WOODMERE 250 CUYAHOGA HTS nn wnT Ann rririPR INSTRUCTIONS FOR COMPLETING EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT (FORM 11) FOR R.I.T.A. MUNICIPALITIES It is required that on or before the last day of each month, the taxes withheld in the previous month be paid and Form 11 filed with R.I.T.A. However, if the amount withheld in any one month for a municipality is less than $100.00, the employer may defer the filing of Form 11 and the payment of the amount withheld until the last day of the month following the end of the calendar quarter. Please check the appropriate box on the front of Form 11 to designate whether this is a monthly or quarterly return. 1. Place the amount of total wages, salaries, commissions, etc., subject to withholding tax for R.I.T.A. municipalities on line 1 of Form 11. 2. Place the amount of municipal taxes withheld for the period on line 2. 3. If you have any adjustments to the municipal taxes you have reported for the previous months of this calendar year, then place those adjustments on line 3 of Form 11. Also print on the back of Form 11 the reason for the adjustments or attach a printed or typewritten letter. 4. Subtract line 3 from line 2 and place that amount on line 4 of Form 11. This is the amount of tax due. List the amount of taxes for each municipality next to the name of the municipality where the taxes are due. PLEASE MAKE CHECK OR MONEY ORDER PAYABLE TO R.I.T.A. ENCLOSE CHECK OR MONEY ORDER AND ORIGINAL COPY OF FORM 11 IN THE ENCLOSED RETURN ENVELOPE. RETAIN DUPLICATE COPY OF FORM 11 FOR YOUR RECORDS. If you have any questions regarding the completion of this form, please call 398-8400. CHANGES If your mailing address, company name, trade name or R.I.T.A. city where located is incorrect or has changed from that shown on Form 11, enter all changes on the form next to the information that has changed. EXPLANATION OF LINE 3 ADJUSTMENTS: OFFIC- USE ON! V P $______EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT REGIONAL INCOME TAX AGENCY T $ 5805 VALLEY BELT ROAD INDEPENDENCE, OHIO 44131 I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT..———————— ————5————— ERSE S P______[THIS FORM MUST BE RETURNED WITH REMITTAN( 1 MAKE CHECKS PAYABLE TO R.I.T.A. MAIL TO: R.I.T.A. ^•-•*" ' J -- 'DATE Form P. O. BOX 6600-T 19 FEDERAL EMPLOYER PERIOD ENDING IDENTIFICATION NO. DATE CLEVELAND, OHIO 44101 R.I.T.A. CITY WHERE LOCATED MONTHLY RETURN a QUARTERLY RETURN LINES 1, 2 AND 4 MUST BE COMPLETED 1. TOTAL WAGES SUBJECT TO _ WITHHOLDING TAX g 2. AMOUNT OF TAXES WITHHELD 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR $. (EXPLAIN ON BACK OF FORM) DO NOT CROSS OUT INCORRECT INFORMATION 4. BALANCE DUE ANDPAID HEREWITH $. t. /Ml ALL MUNICIPALITIES LISTED BELOW HAVE A TAX RATE OF 1% •DISTRIBUTE BELOW EXCEPT CUYAHOGA HTS WHICH HAS A TAX RATE OF %%. *DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT 010 AURORA $ 250 CUYAHOGA HTS I $ 500 MIDDLEBURG HTS $ 720 SEVEN HILLS $ 040 BAY VILLAGE 277 ELYRIA 34/.00 520 MORELAND HILLS 750 SHAKER HTS /-N r SHEFFIELD 060 BEDFORD 300 FAIRVIEW PARK 540 NEWBURGH HTS \752 VILLAGE 090 BENTLEYVILLE 320 GARFIELD HTS 550 NORTH OLMSTED (jft '7,70 SOUTHS UCLID 100 BEREA 370 HIGHLAND HTS 565 NORTH } RIDGEVILLE _Jm5 Ism^T^BQF^ 130 BRECKSVILLE 390 INDEPENDENCE 580 OAK WOOD 2 180 CHAGRIN FALLS 460 MAPLE HTS 650 PEPPER PIKE 820 WALTON HILLS 210 CLEVELAND HTS 480 MAYFIELDHTS 660 REMINDERVILLE 840 WESTLAKE MAYFIELD 485 VILLAGE 670 RICHMOND HTS 900 WOODMERE * nn NOT Ann ririps ; USE ONLY P $ EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT I $ REGIONAL INCOME TAX AGENCY T S 5805 VALLEY BELT ROAD INDEPENDENCE, OHIO 44131 INSTRUCTIONS ON REVERSE SIDE I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT. THIS FORM MUST BE RETURNED WITH REMITTAN MAKE CHECKS PAYABLE TO R.I.T.A. MAIL TO: R.I.T.A. TITLE Form P. O. BOX 6600-T FEDERAL EMPLOYER IDENTIFICATION NO. CLEVELAND, OHIO 44101 R.I.T.A. CITY WHERE LOCATED MONTHLY RETURN D QUARTERLY RETURN LINES 1, 2 AND 4 MUST BE COMPLETED 1. TOTAL WAGES SUBJECT TO _|OC WITHHOLDING TAX $J^7ftrJ 2. AMOUNT OF TAXES WITHHELD 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR $. (EXPLAIN ON BACK OF FORM) DO NOT CROSS OUT INCORRECT INFORMATION 4. BALANCE DUE AND PAID HWEWITH $ ALL MUNICIPALITIES LISTED BELOW HAVE A TAX RATE OF 1% 'DISTRIBUTE BELOW EXCEPT CUYAHOGA HTS WHICH HAS A TAX RATE OF '/2%. *DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMQUN1 010 AURORA $ 250 CUYAHOGA HTS $ 500 MIDDLEBURG HTS $ 720 SEVEN HILLS : $ ! 040 BAY VILLAGE 277 E.LYRIA 2S6.11 520 MORELAND HILLS 750 SHAKER HTS SHEFFIELD 060 BEDFORD 300 FAIRVIEWPARK 540 NEWBURGH HTS 752 VILLAGE ' 090 BENTLEYVILLE 320 GARFIELD HTS 550 NORTH OLMSTED 770 SOUTH EUCLID NORTH 100 BEREA 370 HIGHLAND HTS 565 775 STREETSBORO RIDGEVILLE ^ L 130 BRECKSVILLE 390 INDEPENDENCE 580 OAKWOOD 780 STRONGSVILLE $ f 140 BROADVIEW HTS 400 LAKEWOOD 590 OLMSTED FALLS ( /Y 800 UNIVERSITY HTS 160 BROOKLYN HTS 440 LYNDHURST 600 ORANGE 9 810 VALLEY VIEW Vw \ XTd> " 180 CHAGRIN FALLS 460 MAPLE HTS 650 PEPPER PIKE , ,{) \ 820 WALTON HILLS 210 CLEVELAND HTS 480 MAYFIELD HTS 660 ____REMINDERVILL_ :—— —E j 840 WESTLAKE MAYFIELD tf , LINES 1, 2 AND 4 MUST BE COMPLETED ai 1. TOTAL WAGES SUBJECT TO -ICC WITHHOLDING TAX $. 3. ADJUSTMENTS FOR PREVIOUS MAKE ALL CHANGES ABOVE MONTHS OF CALENDAR YEAR $. (EXPLAIN ON BACK OF FORM) DO NOT CROSS OUT INCORRECT IN FORMATION 4. BALANCE DUE AND PAID HEREWITH $. ALL MUNICIPALITIES LISTED B|LOW HAVE A TAX RATE OF 1% •DISTRIBUTE BELOW EXCEPT CUYAHdGA HTS WHICH HAS A TAX RATE OF %%. *DISTRIBUTIOIM OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK, PERFORMED CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT CODE MUNJ.CfPA LI T Y AMOUNT CODE MUNICIPALITY MOUNl 010 AURORA $ 250 CUYAHOGA HTS j $ 500 MIDDLEBURG HTS <$ , - 720 SEVEN HILLS $ 040 BAY VILLAGE 277 ELYRIA •*?*,*/• 520 .MORELAND HILLS 750 SHAKER HTS SHEFFIELD 060 BEDFORD 300 FAIRVIEWPARK | 5.40 NEWBURGHiHTS.. 752 VILLAGE 090 BENTLEYVILLE 320 GARFIELD HTS 550 NORTH OLMSTED 770 SOUTH EUCLID NORTH 100 BEREA 370 HIGHLAND HTS 565 775 RIDGEVILLE STREETSBORO 130 BRECKSVILLE 390 INDEPENDENCE 580 OAKWOqD 780 STRONGSVILLE 140 BROADVIEW HTS 400 LAKEWOOD 5^0 OLMSTED FALLS 800 UNIVERSITY HTS '160 BROOKLYN HTS 440 LYNDHURST 600 ORANGE 810 VALLEY VIEW .»180 CHAGRIN FALLS 460 MAPLE HTS 650 PEPPER PIKF 820 WALTON HILLS 210 CLEVELAND HTS 480 MAYFIELD HTS 660 REMINDER'VILLE 840 WESTLAKE MAYFIELD 485 670 RICHMOND HTS VILLAGE 900 WOODMERE nn MOT Ann riripc: OFFICE USE ONLY P $______EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT I $ ______REGIONAL INCOME TAX«AGENCY T $ ______5805 VALLEY BELT ROAD INDEPENDENCE, OHIO 44131 INSTRUCTIONS ON REVERSE SIDE I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT. THIS FORM MUST BE RETURNED WITH REMITTAN MAKE CHECKS PAYABLE TO R.I.T.A. MAIL TO: R.I.T.A. Fornr FEDERAL . IDENTIFICATION NO. P. O. BOX 6600-T 1 R.I.T.A. CITY WHERE LOCATED CLEVELAND, OHIO 44101 MONTHLY RETURN D QUARTERLY RETURt^ LINES 1, 2 AND 4 MUST BE COMPLETED 1. TOTAL WAGES SUBJECT TO WITHHOLDING TAX 2. AMOUNT OF TAXES WITHHELD $. 3. ADJUSTMENTS FOR PREVIOUS MONTHS OF CALENDAR YEAR $ MAKE ALL CHANGES ABOVE (EXPLAIN ON BACK OF FORM) DO NOT CROSS OUT INCORRECT INFORMATION 4. BALANCE DUE AND PAID HEREWITH & 3/V/. ALL MUNICIPALITIES LISTED BELOW HAVE A TAX RAJE OF 1% •DISTRIBUTE BELOW if~'T- EXCEPT CUYAHOGA HTfS WHICWHICH HAHAS AA TATAX RATRATE OOF %%Va%.. \ *DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD (p 1 CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT CODE MUNICIPALITIPA Y AMOUN 010 AURORA $• 250 CUYAHOGA HTS !$' 500 MIDDLEBURG HTS $ 720 SEVEN HILLS $ 040 BAY VILLAGE 277 ELYRIA t£4tyL$£_ 520 MORELAND HILLS 750 SHAKER HTS SHEFFIELD 060 BEDFORD 300 FAIRVIEWPARK 540 NEWBURGH HTS 752 VILLAGE 090 BENTLEYVILLE 320 GARFIELD HTS 550 NORTH OLMSTED 770 SOUTH EUCLID 100 BEREA 370 HIGHLAND HTS 565 NORTH RIDGEVILLE 775 STREETSBORO 130 BRECKSVILLE 390 INDEPENDENCE 580 OAKWOOD 780 STRONGSVILLE 140 BROADVIEW HTS 400 LAKEWOOD 590 OLMSTED FALLS 800 UNIVERSITY HTS 160 BROOKLYN HTS 440 LYNDHURST 600 ORANGE 810 VALLEY VIEW . 180 CHAGRIN FALLS 460 MAPLE HTS 650 PEPPER PIKE 820 WALTON HILLS 210 CLEVELAND HTS 480 MAYFIELD HTS 660 REMINDERVILLE 840 WESTLAKE MAYFIELD DO NOT ADD CITIES 485 670 RICHMOND HTS VILLAGE 900 WOODMERE " OFFICE USE ONr,Y""" .p s______: • EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT REGIONAL INCOME TAX AGENCY ; 5805 VALLEY BELT ROAD INDEPENDENCE, OHIO 44131 INSTRUCTIONS ON f HAVE EXAMINED THIS RETURN AND TO THE BEST Q> MY KNOWLEDGE IT IS CORRECT. THIS FORIWlMU$TBE RETURNED WITH RgftBttAN MAKE CHECKS PAYABLE TO RJ.T.A. DATE MAIL TO: R.I.T.A. Form PERIOD ENDING I NO. DATE P. O. BOX 6600;T 1£ R.I.T.A. CITY WHERE LOCATED CLEVELAND, OHIO 44101 MONTHLY RETURN D QUARTERLY* LINES 1, 2 AND 4 MUST BE COMPLEf Epr 1. TOTAL.WAGES SUBJECT TO ** •~jgf^Bjjqpi^^^^'^!igjF^^- _JCC <§ 2. AMOUNT OF .TAXES WITHHELD $. 3. ADJUSTMENTSlif PREVIOUS MONTHStJF CALENDAR YEAR $. •'• MAKE ALL CHANGES ABCft/E (EXPLAIN QNTSAcfKap FORM) DO NOT CROSS OUT INCORRECT IN FORMATION 4. BALANCE.DUE AND PAID HERE WITH $. AILMUJVLICIPACITIES LI.STED BELOW HAVE A TAX RATE OF 1% •DISTRIBUTE BELOW EXCEPT CU,YAH0<3A HTS WHICH HAS A.T|^X ftATE OF %%. *DISTRIBUTION Of; EMPLOYER'S MUNICIPAL TAXES'WITHHELD CITYlWHERE WORK PERFORMED , & /00 CODE MUNICIPALITY - AMOUNT . CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUN1 010 AURORA $ 250 CUYAHOGA HTS $ 500 MIDDLEBURG HTS $" 720 SEVEN HILLS $ ,040 BAY VILLAGE ' 277 ELYRIA W7.S7 520 MORELANDHILLS - '• - ' v. .'f 750 SHAKER HTS : — SHEFFIELD 060 BEDFORD " 300 FAIRVIEWPARK . 540 NEWBURGH HTS • ' - „ f , ' 752 VILLAGE 090 BENTLEYVIL,!^ _ 320 GARFIELD H.T5 550 NORTH OLMSTED 770 SOUTH EUCLID - • 'r NORTH 100 BEREA 370 HIGHLAND HTS 565 775 STREETSBORO ... RIDGEVILLE 130 BRECKSVILLE: 390 INDEPENDENCE 580 OAKWOOD 780 STRONGSVILLE '•••V.^ —— :140 BROADVIEW HtS 400 LAKEWOOD '": ' 590 OLMSTED FALLS 800 UNIVERSITY HTS -' 160 BROOKLYN HTS~ 440 LYNDHURST . 600 ORANGE '"; . 810 VALLEY VIEW 180 CHAGRIN FALt'9- - 460 MAPLE HTS :""••'•' 650 PEPPER PIKE „•• :•.-/-;. 820 WALTON HILLS ;210 CLEVELAND HttS- • - ' .. : .; 480 MAYflEL.D HTS 660 REMINDERVILLE --: ,'. .-f '. 840 WESTLAKE MAYFIELD , DO NOT AQP CITIES 485 670 RICHMOND HTS ••• '• ••»: *-•"• . - ."•- • VILLAGE -^.,. • . .- 900 WOODMERE OFFICE USE ONLY P $______EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT I $______REGIONAL INCOME TAX AGENCY T $______5805 VALtEY BELT ROAD INDEPENDENCE, OHIO 44131 I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT THIS FORM MUST BE RETURNED WITH REMITTAN MAKE CHECKS PAYABLE TO R.I.T.A. :i.T.A. Form FEDERAL EMPUDYER IDENTIFICATION NO. O. BOX 6600-f R.I.T.A. CITY WHERE LOCATED MONTH L Y QUARTERLY RETURN LINES 1/2pPEg4 MUST BE COMPLETED 1. TOTAL WAGES SUPJECY TO WITHHOLDING' 2. AMOUNT OF TAXES WITHHELD $. 3. ADJUSTMENTS F&R PREVIOUS MONTHS OF CALENDAR YEAR MAKE ALL CHANGES ABOVE (EXPLAIN ON BACK OF FORM) 4. BALANCE DUE AND PAID HEREWITH $. 'DISTRIBUTE BgtOW INSTRUCTIONS ON REVERSE SIDE ^DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED ! CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUN' 010 AURORA $ 250 CUYAHOGA HTS $ 500 MIDDLEBURG HTS $ ."' ' ~ 750 SHAKER HTS $ SHEFFIELD 040 277 ELYRIA 520 MORELANO HILLS 752 c- *, BAY VILLAGE . * 30?. ?/ '••'•: *,' VILLAGE 060 BEDFORD 300 FAIRVIEWPARK 540 NEWBURGH HTS 770 SOUTH EUCLID 090 BENTLEYVILLE 320 GARFIELD HTS 550 NORTH OLMSTED 775 STREETSBORO 100 BEREA 370 HIGHLAND HTS j 580 OAKWOOD 780 STRONGSVIJ.LE ———— 'iauAQ— ipo BRECKSVILLE 390 INDEPENDENCE 6*90 OLMSTED FALLS V: 800 UNivEB^ijjpTTrs 140 • BROADVIEWHTS 400 LAKEWOOD j|L_ 600 ORANGE VALLfiKvJEW \ 3rr ; - . jjfi!) m\* v»^l 160 BROOKLYN HTS 440 LYNDHURrSfr 650 PEPP'ER PIKE 820 w)«TON HILLS \\ = "V • — ^. fr ——————— ——— 180 CH/&RIN FALLS 460 MAPLE HTS 660 REMINDERVILLE ——— ig* JWESTLAKE :**, 210 CLEVELAND HTS 480 MAYFIELDHTS 670 RICHMOND HTS 900 WOODMERE MAYFIELD 485 SEVEN HILLS DO NOT ADD CITIES VILLAGE 720 i OFFICE USE ONLY ; P $;______EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT ; i . $__.._____ REGIONAL INCOME TAX AGEMCY T, $ ___-.______5805 VALLEY fl^tT ROAD INDEPENDENCE, OHIO 44131 I HAVE EXAMINED THIS^STURN AND^O THE BEST OF MY LEDGE IT IS CORRECT. THIS FORM MUSTffE RETURNED WITH MAKE CHECKS PAYABLE MAIL TO: R.I.T.A. Form 1 p. O. BOX 6600-T 197 CLEVELAND, OHIp 44101 MONTHLY RETURN :\ O.UARTERL YRETURN [ LINES 1, 2 A$0 4 MUST BE COMPLETED 1. TOTAL WAGES SUBJECT TO WITHHOLDING TAX,., 2. AMOUNT OF TAXE§.V\/ITHHEL("> $_ 3. ADJUSTMENTS FOR'ffflEVIOUS M O N T H S O F C A L E NOA R Y E A R $ .. ALL GRANGES ABOVE !L XI'I. Ai\l ON BAC K-Of FORM) DO NOT INFORMATION 4. BALANCE DUE AMD:t>;AID HEREWITH S. to 'DISTRIBUTE BELOW INSTRUCTIONS ON IVERSE SIDE *DrSfRlBUTION OF f|PLOYER'S MUNICIPAL TAXES WITHHELD :! BASED OMSEITY WHERE WORK PERFORMED ^ : ••»' J" ' -.! ••-'"'•, '-' ' ' ' ' ;"- ' • • , •. ;ODE MUNICIPALITY AMOUNT CdDF. MUNICIPAL ITY^'' . AMOl'NT CODE MUNICIPALITY AMOUNT ; jVODE :'/tUN i C> P AL i'T Y /;:T A VIOUNT 010 AURORA ! '•£>, • ' .Xj" CUYAHOGA HTS.'l .500 MIDDLEBURG HTS s 750 SHAKER HTS .•':' : S ^ '$• L | :i.^ . * " SHEFFIELD ."'••• '"' 040 BA - VILLAGE; ^7 ELYRIA '-jL' 520 MOR&LAIMD HILLS 752 •< >K w 130 BR CKSVILl. b :;: ',*. ' ' !.'.'• 3?" IN3I PENDENC-* 590 OLMS'.TLD FAL LS •Jj>. 800 LIT I-., ERillTY jfiTS 140 BRi. 'ADVIEW HTSf: •'490 L/'K WOOD "&'i 600 ORANGE- "'1| 810 VX-L^LFY VIEvil '' • -!•- 160 BRi )OKI. YN HTS \ 440 L\ N 'JHURS'f v,". ' 650 PEPPER PIKE 820 WM.mNNALlS * sb 180 CH/vGRHM FALLS : 460 M/xPLR HTS •.••»1 660 REM!NlJEt'VM I. E ;., 840 ~'FTT§r— W AJ - ——————————— t§/ J¥ K 0^ 210 CLl VELAND HTS 4SO MAYFie.LD HTS; .... 670 RICHMOND NT'S 900 V^DMW(= ^ r., *A MAY FIELD ^-^--^ DO NOT ADD CITIES 485 720 SEVEN HILLS VlLl. AGf: -REGIONAL INCOME TAX AGENCY RECONCILIATION OF RETURNS FORM 17 P.O. BOX 7777 Of Income Tax Withheld |Form 11) INDEPENDEf'^E, OHIO 44131 With Forms W-2 Submitted Herewith 1. Total Number of Employees 3. Total Income Tax Withheld from compensation during Total Number of W-2 Forms Enclosed lf6 1973 as shown by Form 11 for the period: JANUARY $______JULY $______2. Total RITA Wages Paid $f,2ff*&6 FEBRUARY ^, v AUGUST STATEMENT DATE | ^ &"~ T- ^~ '^* DUE DATE |U4~.4U- it •MARCH t af PRIL Federal Employer '.i4 .;|ji| OCTOBER Identification No. 3 'r 0 4 2 0 hi 8 4 PAY •••:;• j, NOVEMBER lj +JSUNE 'DECEMBER * ~ ILffi , , ~ •*•••?»''?; 4^This tjitaI should equal i% • O'-ITT.S CHC^::IOAL C. G-•••'•-' : of line 2 except Cuyahdga Hts. TOTAL $—-L 1-^ LUCUST $T P( .. PHX 375 •if quarterly payments A*t» made, monthly breakdown not U YR I A OH 4iv03r. : cftqyjred. Explain fully any discrepancy on back of this Form. •V.P. TAXPAYER'S COPY Signature/^ Title Date CO t-» ON Ol r\> _T1 (Jl -Cx 3N r\J jj O\CO-J1-*^ TO 33 ON o J co o H* 4V 45. f\3 O O CX> -0 O ON O 1 en co o ro CO AJ wJ wJ -j r\> -?>• vo cn v/i -J ON cr\ ro -J co i- o o ON ui ~j o uj i-^ ro INSTRUCTIONS FOR COMPLETING EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT (FORM 11) FOR R.I.T.A. MUNICIPALITIES Effective January 1, 1972, it will be required that on or before the last day of each month, the taxes withheld in the previous month be paid and Form 11 filed with R.I.T.A. However, if the amount withheld in any one month for a municipality is less than $100.00, the employer may defer the filing of Form 11 and the payment of the amount withheld until the last day of the month following the end of the calendar quarter. Please check the appropriate box on the front of Form 11 to designate whether this is a monthly or quarterly return. 1. Place the amount of total wages, salaries, commissions, etc. subject to withholding tax in R.I.T.A. municipalities on line 1 of Form 11. Do not include payroll on Line 1 against which there is no withholding for R.I.T.A. (e.g., em- ployees under age with no withholding or that part of payroll where tax is paid another agency). 2. List the amount of municipal taxes that are being withheld for each municipality in the space provided next to the name of that municipality listed on the bottom part of Form 11. Then place the total taxes withheld for all munici- palities on Iine 2 of Form 11. 3. If you have any adjustments to the municipal taxes you have reported for the previous months of this calendar year, then place those adjustments on line 3 of Form 11. Explain adjustment as to tax withheld and wages subject to tax on back of form or in letter attached to Form 11. 4. Subtract line 3 from line 2 and place that amount on line 4 of Form 11. This is the amount of tax due. PLEASE MAKE CHECK OR MONEY ORDER PAYABLE TO R.I.T.A. ENCLOSE CHECK OR MONEY ORDER AND ORIGINAL COPY OF FORM 11 IN THE ENCLOSED RETURN ENVELOPE. RETAIN DUPLICATE COPY OF FORM 11 FOR YOUR RECORDS. MAIL TO: R.I.T.A., Post Office Box 6600-T, Cleveland, Ohio 44101 If you have any questions regarding the completion of this form, please call 398-8400. CHANGES If your mailing address,company name, trade name or R.I.T.A. city where located is incorrect or has changed from that shown on Form 11, please check the box provided on the front of Form 11. PLEASE enter all changes on the CORRECTION FORM at the bottom of this page and ATTACH TO your with- holding statement and remittance. TEAR ALONG DOTTED LINE (Please print or type) CORRECTION FORM FEDERAL EMPLOYER IDENTIFICATION NO. Please enter all information below and circle the numbers of any items which have changed. Today's Date ______ Date Change was effective_ 2. Company Name ____ 3. Trade Name, Division or c/o. 4. Mailing Address ______ 5. R.I.T.A. City where Work Performed (If more than one, write "MULTIPLE"). Signature. Form 11A 3-24-72 FORM 17 KKCONCH-lAftURUI- KtllWNS 1972 Of Income Tax Withheld (Form 11) 1972 Regional Income Tax Agency With Forms W-2 Submitted Herewith Do Not Remit with this Form; 1. Total Number Of Employees. For Reconciliation Purposes Only. 2. Total Tax Withheld From Employees. $ f,}ij2,0lf' 3. Total Income Tax Withheld from compensation during 1972 as shown by Form 11 for the period: Federal Emplay.r Identification No. Mf 9 ? IP P f l» i/ Qaygny_____ JANUARY $______JULY FEBRUARY yjfg .,„ AUGUST •MARCH _*5£JL(W_. SEPTEMBER APRIL ______OCTOBER Street MAY -iJriC jgf» NOVEMBER •JUNE 2gO. Oy >nFrFMRFR '' /City / x, / , Sta M 4. Signattj^ Title Date If quarterly payments were made, monthly breakdown not required. Items 1 and 4 should be identical. Explain fully any discrepancy Retain This Copy For Your Records on back of this Form. EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT REGIONAL INCOME TAX AGENCY TEL (2TB) 39U-8400 (CHECK ONE) FORM 11 FEDERAL EMPLOYER PERIOD ENDING MONTHLY RETURN CD IDENTIFICATION NO. DATE 1972 QUARTERLY RETURN _] R.I.T.A. CITY WHERE LOCATED DO NOT MAKE CHANGES ON THIS FORM THEY CANNOT BE RECORDED FROM THIS PAGE. ALL LINES MUST BE COMPLETED USE CORRECTION FORM ON INSTRUCTION SHEET. 1. TOTAL WAGES SUBJECT TO WITHHOLDING TAX 2. AMOUNT OF TAXES WITHHELD $_ }< DISTRIBUTE BELOW 3. ADJUSTMENTS FOR PREVIOUS $. MONTHS OF CALENDAR YEAR (EXPLAIN ON BACK OF FORM) CORRECTION FORM ATTACHED. 4. BALANCE DUE AND PAID HEREWITH $ . I kf»VE EXAMINES THIS RETURN AMD TO THE BEST OF MY KtMJJWLEOGE IT IS CORRECT. THIS FORM MUST BE RETURNED WITH REMITTANCE SIGNATURE ^ TITLE 1/25/73DATE MAKE CHECKS PAYABLE TO R.I.T.A. THIS FORM MUST BE SIGNED. MAIL TO: R.I.T.A. P.O. BOX 6600-T CLEVELAND, OHIO 44101 DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT DO NOT ADD CITIES TO LIST ALL MUNICIPALITIES LISTED ABOVE HAVE A 1% MUNICIPAL FORM 11 INCOME TAX RATE, WITH THE EXCEPTION OF CUYAHOGA HEIGHTS 3/24/72 WHOSE TAX RATE IS 1/2%. EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT REGIONAL INCOME TAX AGENCY TEL. (216) 398-8400 (CHECK ONE) FORM 11 FEDERAL EMPLOYER PERIOD ENDING MONTHLY RETURN CU IDENTIFICATION NO. DATE 1972 QUARTERLY RETURN Ijiji R.I.T.A. CITY WHERE LOCATED DO NOT MAKE CHANGES ON THIS FORM THEY CANNOT BE RECORDED FROM THIS PAGE. ALL LINES MUST BE COMPLETED USE CORRECTION FORM ON INSTRUCTION SHEET. 1. TOTAL WAGES SUBJECT TO 28J22.W §3 WITHHOLDING TAX s I 2. AMOUNT OF TAXES WITHHELD $. 287.21 IS JJC DISTRIBUTE BELOW 3. ADJUSTMENTS FOR PREVIOUS $ MONTHS OF CALENDAR YEAR CORRECTION FORM ATTACHED. (EXPLAIN ON BACK OF FORM) 4. BALANCE DUE AND PAID HEREWITH S. 287.21 I HAVE EXAMINED THIS RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT. THIS FORM MUST BE RETURNED WITH REMITTANCE '*M P. 1 0/102 SIGNATUREff TITLE PATE MAKE CHECKS PAYABLE TO R.I.T.A. THIS FORM MUST BE SIGNED. MAIL TO: R.I.T.A. P.O. BOX 6600-T CLEVELAND, OHIO 44101 DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD BASED ON CITY WHERE WORK PERFORMED CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT 010 AURORA 370 HIGHLAND HTS 650 PEPPER PIKE 040 BAY VILLAGE 390 INDEPENDENCE 670 RICHMOND HTS 060 BEDFORD 400 LAKEWOOD 720 SEVEN HILLS 100 BEREA 440 LYNDHURST 750 SHAKER HTS SHEFFIELD 130 BRECKSVILLE 460 MAPLE HTS 752 VILLAGE 140 BROADVIEWHTS 480 MAYFIHLD HTS 770 SOUTH EUCLID 160 BROOKLYN NTS 485 MAYFIIELD VILLAGE 775 STREETSBORO 180 CHAGRIN FALLS 500 I MIDDLEBURG HTS 780 STRONGSVILLE 210 CLEVELAND HTS 520 MORELAND HILLS 800 UNIVERSITY HTS 250 CUYAHOGA HTS 540 NEWBURGH HTS 810 VALLEY VIEW 277 ELYRIA 287 \2 550 NORTH OLMSTED 820 WALTON HILLS 300 FAIRVIEWPARK 580 OAKWOOD 840 WEST LAKE 320 GARFIELDHTS 590 OLMSTED FALLS 900 WOODMERE DO NOT ADD CITIES TO LIST TOT A I (INSERT ON „. ALL MUNICIPALITIES LISTED ABOVE HAVE A 1% MUNICIPAL IUIAL LINE2ABOVE) $ FORM 11 INCOME TAX RATE, WITH THE EXCEPTION OF CUYAHOGA HEIGHTS 3/24/72 WHOSE TAX RATE IS 1/2%. G jtf / City of Cleveland OFFICE VOUCHER No. 423-22717 Date J«ly 26. i»72 34-04208*4 TO Obitt* Ch«*lcal Co. 142 teenst St. Bex 37S fclyri*. Ofcio 4403$ Date Explanation Amount Kcftaui for wtAicipal iucoa* t«* for x*«r •mdifig 1971 $40.00 /^- f/4;/^ ^^ ' Footing* and Extension* Correct APPROPRIATION DISTRIBUTION LOCAL Amount Amount Clerk, Dir. of Accounts 277 Approved for Payment $46.00 425 F. 2760 $40.00 Director REMITTANCE SLIP OFFICE USE ONLY P $ ______EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT REGIONAL INCOME TAX AGENCY 1217 VALLEY BELT ROAD BROOKLYN HEIGHTS, OHIO 44131 $ __. 'CHECK ONE) t FQRM1 FEDERAL EMPLOYE* MONTHLY RETURN -Q IDENTIFICATION NO. 1972 QUARTERLY RETURN LJT R.I.T A. CITY WHe RE LOCATED STREET ADDRESS:-. ___ please prirt 1. TOTAL WAGES SUBJECT TO WITHHOLDING TAX 21, *72-73 2. AMOUNT OF TAXES WITHHELD 3. ADJUSTMENTS FOR PREVIOUS MONTHS OF CALENDAR YEAR if CHANGES OF NAME. ADDRESS OR CITY OF BUSINESS MUST ——. (EXPLAIN ON BACK OF- FORM) BE RECORDED ON INSTRUCTION SHEET AMD RETURNED. _) 4. BALANCE DUE AND PAID HEREWITH I I HAVE EXAMINED THI ! RETURN AND TO THE BEST OF MY KNOWLEDGE IT IS CORRECT. THIS FORM MUST BE RETURNED WJ TH REMITTANCE )&4><-4& SIGNATURE JrMP W» 1f7* MAKE CHECKS PAYABLE TO R.I.T.A. DISTRIBUTION OF EMPLOYER'S MUNICIPAL TAXES WITHHELD COOE MUNICIPALITY AMOUNT CODE MUNICIPALITY AMOUNT COPJE VHJNK:i"AUTY AMOUNT 370 HIGHLAND HTS 650 PEPPER PIKE 010 AURORA $ $ 040 BAY VILLAGE 390 INDEPENDENCE 670 RICHMOND NTS 060 BEDFORD 400 LAKEWOOD 720 SEVEN HILLS 09 J BENTLEYVILLE 440 LYNDHURST 750 SHAKER HTS ...... ' L •' S'HEFFIEL : 100 BEREA 460 MAPLE:iHTS 752 „.. . _„ ...... ' VILLAGE 130 8REOKSVI LE 480 MAYFIELD HTS 770 SOUTH EUCLID MAYFI6LD 140 BROADVIEW HTS 485 1: 775 STREETSBORO .i VILLAGE i -_i BROOKLYN HTS 500 MIDDLEBURG HTS 780 • STRONGSVILLE 180 CHAGRIN ! ALLS 520 MORELAND HILLS 800 UNIVERSITY HTS 210 CLEVELAND HTS 540 NEWBURGH HTS 810 VALLEY VIEW 250 CUYAHOGA HTS 550 NORTH OLMSTED 820 W ALTON hi ILLS ...... ———— -— - —— 27 ELYRIA 286. 6 DUPLl( kTE i .,! -rr»TAi (INSERT ON * _ os /- ALL MUNICIPALITIES LISTED ABOVE HAVE A 1% MUNICIPAL TOTAL Ll^e 2 ABOVE 1 $ 2O0.6fi __Ci__I FORM 11 INCOME TAX RATE, WITH THE EXCEPTION OF CUYAHOGA HEIGHTS WHOSE TAX RATE IS 1/2%. t,*)' T 'C 7 CITY OF CLEVELAND MUNICIPAL INCOME TAX DIVISION CENTRAL COLLECTION AGENCY 1701 LAKESIDE AVENUE • CLEVELAND, OHIO 44114 • PHONE: 2H/894-1070 July 7, 1972 LOUIS V. CORSI IN REPLY REFER TO: ADMINISTRATOR Obitts Chemical Company 142 Locust St. Box 375 Elyria, Ohio 44035 Identification No. 54 0420884 Aurora Bay Village BMChwCKMl Period Ended ..... 12-31-69-70-71 Bedford Beattoyvilto Bratenahl Dear Taxpayer: BmctovBta BtoMvtew Hte. Brooklyn Hto. A review has been made of your Municipal Income Tax Return for the Chagrtn FiUb Clttxdon period shown above. Clanlaod CtovrtandHt*. CuyafaowBta. In order to complete our review it will be necessary for you to submit KaftOewland Bactlak* the information checked on the reverse side of this letter. Blrrta Euclid FaJntewfuk If you have any questions regarding this matter contact this office GaxOeklHte immediately, otherwise, please submit the requested information within ten (10) days. Lakcwood Your cooperation is appreciated. MapteHU. MayficldHta. Very truly yours, May field VUlace Mwtoz rthe-Laki Hta. Moqiand Hlll« K. Dever MTwirtwiMh Hts. Tax Auditor North Olmsted North Randall Oakwood :eb ObUtedFaUi ,/ •/ Rlciim Ht*. / au. Vil South Bhiclld 7- /J- Stront*vffle Tta*b«rlake Hta, WaltonHOli Wammwme Hta. WwOaka WfeUUfe wAoofbby WIBoutbby Hilla Wfflo^k Woodmen CCA:3M FEDERAL SCHEDULES LETTERS FROM EMPLOYER VERIFYING ADDITIONAL INFORMATION ( ) SCHEDULE C - 10MO ( ) Tax withheld incorrectly and an ( ) Copy of Birth Certificate explanation ( ) SCHEDULE E - 10MO ( ) Exact city of Employment ( ) Distribution of taxes withheld () 1120 ( ) Social Security Numbers ( ) Business expenses claines are 1120 - SCHEDULE A necessary and not reimbursed ( ) Employer Federal Cost of Goods Sold Identification Number 1969 - 1970 - 1971 ( ) Dates of employment during ( ) 1120 - SCHEDULE D 19___ ( ) Copies of cancelled checks Capital Gains or receipts substantiating ( ) Percentage of time claimed as estimated credit claimed ( ) 1065 employed in non-taxing areas in the amount of $______( ) 1065 - SCHEDULE K ( ) Names, Addresses, Social Partner's share of income Security Numbers and amounts paid to persons on ( ) W-2 - Wage and Tax Statement basis. ( ) 2106 - Business Expense ( ) Complete copy of 19__ ( ) Form 1099 Municipal Tax Return ( ) Schedule of Other Business ( ) Persons rental expense Expenses paid to ( ) Complete enclosed forms and return original ( ) Complete Form 120-19 OFFICE USE ONLY EMPLOYER'S MUNICIPAL TAX WITHHOLDING STATEMENT P $ ______I S ______REGIONAL INCOME TAX AGENCY 1217 VALLEY BELT ROAD BROOKLYN HEIGHTS, OHIO 44131 T $ (CHECK ONE) t FQRM Tt -; FEDERAL EMPLOYER PERIOD Eh^ IDENTIFICATION NO. OATE MONiTHL Y RETURN L J RETURN K.I.T.A. CH'V WHERE LOCATED STREET ADDRESS:____ olease print 1. TOTAL WAGES SUBJECT TO 3£ WITHHOLDING TAX t s <§ j 2, AMOUNT -OF TAXES WITHHELD ' 3. ADJUSTMENTS FOR MONTHS OF CALENDAR CHANQEE'W NAME, ADDRESS OR.C'ITV' OP BUSINESS WrU$T n-s (EXPLAIN' ON BACK OF BE Q^D ON lf4ETRUJ?flO.N,ApEET AND RETURNE0(> LJ 4. BALANCE DUE AND PAID HPftBfritH S THIS FORM MUST BE RETUF&f€D"WITH REMITTANCE • MAKE CHECKS PAYtE TO R.LT.A " DISTRIBUTION OF EMf LOVER'S MUNlClPALTAXES WITHHl 0" ' ,. . • - CODEV '•* '-'WU Mi CI PA LI TY MU.NT • AURORA . , 370 .040- BAY vr. 390 BfGJFORD 400 ~rr^— 090 440 100 BiREA 460 130 ftRECKSVILLH 480 140 BftOADVIEW'HTS 485 i«n fiBOQKL-YN-HTS-- 500 CHAGRIN FALLS 520 MJPHJLAND HILLS 210 CLEVELAND 4TS 540 ,H HTS 810 I,VALLEY VIEW • f;.-; li. 250 CUYAHOGA I-STS 550 Nf flfH 0 .MSTED 820 | WALTON HILLS : 277 ELYRIA 580 840 I W't* soo FAIRVIEWPARK 590 900 320 GAR FIELD HP'S 600 UlteERT ON a, ALL MUNICIPALITIES LISTED ABOV^i^V.E A 1% MUNICIPAL $ 'FORM .1 ] INCOME TAX RATE, V*ITH THE EXCEPTI||j|^FXUYAHOGA HEIGHTS 42/1/71 WHOSE TAX RATE IS,f/2%, ^'^ '' HARRY J. P. WOLTZ, CERTIFIED PUBLIC ACCOUNTANT, ELYRIA, OHIO INSTRUCTIONS FOR FILING ATTACHED RETURN Make check for $_ n payment of: Payable to: _'_ F. I .C.A. & Withholding Tax ___Internal Revenue Service , Federal Income Tax ___Treasurer, ______County Federal Estimated Income Tax ___Bureau Of Employment Services _Federal-State-Unemployment Tax ___Treasurer, State of Ohio JDeposit Unemployment Tax _Central Collection Agency _Deposit Withheld Taxes Other _Workmen's Compensation Insurance _Sales Tax _Persona I Property-Bus i ness-Persona l_ Refund Due Of $ _Franchise Tax & Security Valuation Ma" i I to: i ty-State- I ncome Tax______Internal Revenue Service City-State-Estimated Income Tax_ Cincinnati, Ohio 45298 ~0ther ___Enclosed envelope ___Auditor, ______County Be sure report iaMdated and signed by: Collection Agency 1701 Lakeside, Cleveland, Ohio 44114 Other _Copy enclosed for your records IMPORTANT: To avaoid penalty charges sign and mail report on or before due date even though you do not send the money. ANNUAL FROHBUilHESS, PROFESSION OR OTHER ACTIVITY CONDUCTED BY INDIVIDUALS, PARTNERSHIPS, ESTATES OR TRUSTS, AND RETURN CORPORATION FOR CALENDAR YEAR 1971 FORM f>B FliCAIr VBA» ftfflMMIMB 1Q70 AND ENDING 1971 1971 CCA 120-17 (THIS RETURN MUST BE FILED EVEN THOUGH FINAL COMPUTATION RESULTS IN NET LOSS) NAME ...... ivJc.i.T.t5...Ch^l.ca.»...C«np.?»ny.. FEDERAL IDENT. NO...... 34-0.420384... SECUR|TY N0 ...... TRADE NAME...... MAILING ADDRESS ...... If individual owner, hem* address LOCAL BUSINESS ADDRESS...... 375...... c)Ty ANp Z|P CODE CITY AND ziPcoDE...... Myf.l'!U...QMQ..4.lJfl5g...... NATURE OF BUSINESS n.aciam«»t.Jon .of. . (COMPLETE APPROPRIATE SCHEDULE AND ENTER ONLY ACTUAL TAX OFFICE USE FIGURES HERE) ONLY PROCESSED BY TAXABLE PROFITS FROM: 1. TAXABLE WAGES FROM {SCHEDULE G)______. AUDITED BY 2. PARTNERSHIPS AND ASSOCIATIONS (SCHEDULE A)_, DATE OF AUDIT 3. RENTS (SCHEDULE B)______. APPROVED BY 4. BUSINESS OR PROFESSION (SCHEDULE C)______4MU 5. INCOME FROM ALL OTHER SOURCES (SCHEDULE E). REFUND APPROVED 6. TOTAL TAXABLE INCOME______LOSS- (17310.92) TAX DUE AND CREDITS 7. TAX DUE SEE (INSTRUCTIONS)______(A) CREDIT ALLOWABLE FROM PREVIOUS YEAR RETURN FOR P & I 8. CREDITS: (B) PAYMENTS ON 197< ESTIMATED TAX 4.0 ,'on AUDIT (C) IF AMENDED RETURN, TAX PAID ON~ ~ " ~ PRIOR RETURN______. ALLOCATION (D) TAX WITHHELD FROM (SCHEDULE G)_____ CREDIT (E) TOTAL CREDITS ALLOWABLE______40.300 9. TOTAL DUE AND PAID WITH THIS RETURN (LINE 7 LESS LINE 8 (E)______ 10. OVERPAYMENT CLAIMED (IF LINE 8 '(E) EXCEEDS LINE 7, ENTER DIFFERENCE HERE _ ___ 40^00 IP BUSINESS TERMINATED COMPLETE THIS BLOCK______ 11. ENTER AMOUNT OF LINE 10 YOU WANT CREDITED TO 197___TAX;___$_ IF YOU TERMINATED YOUR BUSINESS 12. ENTER AMOUNT OF OF LINE 10 YOU WANT REFUNDED___ 40.Uu GIVE EXACT DATE ______IF YOU SOLD YOUR BUSINESS (OR ASSETS 4. Were any ef your prior years' Federal Income Tax Returns ,. . „ QUESTIONS, examined and/or changed during 1971? _]Not Examined UPON LIQUIDATION) WRITE PURCHASER'S (Answer fully—us* extra sheat if necessary) QChangad Q Examined but Unchanged NAME 1. Please cheek ell applicable blocktl You are required to inform this office within 30 days of QIndividual Owner any change in your U.S. Tax Return affecting profits, Q Resident ADDRESS ______Qportncrshlp- earnings or expenses. QNon-Resident {ffCorporatlon 5. Did you hove any employees between January 1,1971 and IF BUSINESS ENTITY CHANGED DURING December 31, 1971 QYes Q No 2. Date butlnet* started D Estate or Trust PAST YEAR, MARK APPROPRIATE or trust created, __|5ML______6. On which basis are your records kept? QCash Q Accrual BLOCKS. 3. If you filed e Return far a prior year, QCash and Accrual Combination Q Completed Contract what was the latest year? ______QOther(explain) ______ °rtn8rt''|P QCorp. I HEREBY CERTIFY UNDER THE PENALTIES PROVIDED BY LAW THAT ALL STATEMENTS MADE HEREIN AND/OR IN ANY SUPPORTING SCHEDULE ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. Harry Wot tz, CPA F£B 15 1972 •KMATUW OP PERSON PREPAIaNO RETURN IF NOT TAXPAYER DATE S THIS RETURN MUST BE FILED AND TAX PAID IN FULL ON OR BEF 120 DAYS FROM CLOSE OF YOUR FISCAL, IF FISCAL YEAR IS DIFFERENT FROM THE CALENDAR YEAR) MAKE CHECK OR MONEY ORDER PAYABLE TO: CENTRAL COLLECTION AGENCY. MAIL TO DIVISION OF TAXATION, 1701 LAKESIDE AVENUE, CLEVELAND, OHIO 44114. COPY OF FEDERAL RETURN CAN BE ATTACHED IN LIEU OF COMPLETING SCHEDULE C Page 2 A SEPARATE SCHEDULE MUST BE COMPLETED FOR EACH BUSINESS SCHEDULE C TAXABLE PROFIT (OR LOSS) FROM BUSINESS OR PROFESSION EMPLOYER'S IDENTIFICATION NUMBER...... LINE 1. TOTAL RECEIPTS $______LESS ALLOWANCES, REBATES AND RETURNS ____$ 2. INVENTORY BEGINNING OF YEAR ———————————______$._ 3. MERCHANDISE PURCHASED $______LESS ANY ITEMS WITHDRAWN FROM BUSINESS FOR PERSONAL USE $______4. COST OF LABOR (DO NOT INCLUDE SALARY PAID YOURSELF). 5. MATERIAL AND SUPPLIES ______.______. 6. OTHER COSTS (EXPLAIN IN SCHEDULE C-2)______7. TOTAL OF LINES 2 THROUGH 6 ______.______$._ 8. INVENTORY AT END OF YEAR ______9. COST OF GOODS SOLO (LINE 7 LESS LINE 8) ______£_ 10. GROSS PROFIT (LINE 1 LESS LINE 9) ______.____ _$_ OTHER BUSINESS DEDUCTIONS 11. SALARIES AND WAGES NOT INCLUDED ON LINE 4 (DO NOT INCLUDE ANY PAID TO YOURSELF) $._ »** 12. RENT ON BUSINESS PROPERTY.ISTATE BELOW TO WHOM PAID)______13. INTEREST ON BUSINESS INDEBTEDNESS ______._.______14. TAXES ON BUSINESS AND BUSINESS PROPERTY___*IL^CJl^lll.DJi4L__ __ 15. LOSSES OF BUSINESS PROPERTY (EXPLAIN IN SCHEDULE C-2) ______16. BAD DEBTS ARISING FROM SALES OR SERVICES (EXPLAIN IN SCHEDULE C-2). 17. DEPRECIATION AND OBSOLESCENCE (EXPLAIN IN SCHEDULE C-1) _____'__ 18 REPAIRS ______-______19. OTHER BUSINESS EXPENSES (EXPLAIN IN SCHEDULE C-2) ______20. TOTAL OF LINE 11 THROUGH 19 ______...__ $ 21. TAXABLE PROFIT (OR LOSS) FROM BUSINESS OR PROFESSION (LINE 10 LESS LINE 20) ENTER HERE (IF NET PROFIT INCLUDES NON TAXABLE INCOME COMPLETE SCH. X)______£_ 22. ADJUSTMENT TO TAXABLE INCOME (FROM SCH. X LINE 14 - PAGE 3) ______.. __ _$ 23. ADJUSTED TAXABLE INCOME (LINE 21 PLUS OR MINUS LINE 22 ) 24. A. AMOUNT ALLOCABLE:______% OF LINE 23. SCHEDULE C ONLY - FORM CCA 120-19 AND ATTACHED HERETO______.______...$ 25. LESS ALLOWABLE NET LOSS PER PRIOR YEARS NET PROFIT RETURN (CCA 120-17) ATTACH SCHEDULE...... _...... __..__...... __..._...... __...___...... 26. ADJUSTED TAXABLE INCOME (LINE 21 OR LINE 24 MINUS LINE 25 ENTER HERE f IT'510 AND ONLINE 4, PAGE 1_.,__._...... __..___._....__...._...__...._....__..__._.—_.—._—_-——- _$______^ ' /JIL > .Rent expense (LI2) will not be allowed unless names/s of landlord/s and amount paid each are furnished. ***NAME ______ADDRESS ______. (PROPERTY OWNER'S NAME)______STREET______CITY______ SCHEDULE C-1 EXPLANATION OF DEDUCTIONS FOR DEPRECIATION AND OBSOLESCENCE CLAIMED IN SCHEDULE C 1. Kind Of Property (If Building State Material Of 2. 3. 4. Depreciation 5. Method Of 6. Rate (%) 7. . Which Constructed.) Exclude Land And Other „ , _ _r_° o Allowed (or Allow- Computing Or uecrociaiion Nondepreciable Property. Acquired other Basis awe, in f^ior Years Depreciation Life (Years) For Th,s Year .$._ SCHEDULE C-2______EXPLANATION OF OTHER DEDUCTIONS CLAIMED IN SCHEDULE C Line No. Explanation Amount Line No. Explanation Amount Page 3 SCHEDULE X- RECONCILIATION WITH FEDERAL INCOME TAX RETURN IF USED - FEDERAL RETURN MUST BE ATTACHED - NOT TO BE COMPLETED BY SELF EMPLOYED ITEMS NOT DEDUCTIBLE ADD ITEMS NOT TAXABLE DEDUCT 1. CAPITAL LOSSES (FROM FED SCH. D)______$_____ 8. CAPITAL.GAINS PER FED SCH. D______$_____ 2. EXPENSES INCURRED IN THE PRODUCTIONS 9. INTEREST EARNED OR ACCRUED______$_____ OF NON-TAXABLE INCOME (ABSENCE OF AC- 10. DIVIDENDS (LESS FED. EXCLUSION)______$_____ TUAL RECORDS-EXPENSES EQUAL TO 5% OF NON-TAXABLE INCOME)______$_____ 11. INCOME FROM PATENTS AND COPY RIGHTS____ $_ 3. ALL INCOME TAXES PAID OR ACCRUED______$_ 12. OTHER (EXPLAIN)————————————————————— $_ 4. PAYMENTS TO PARTNERS______$______5. NET OPERATING LOSS (PER FED RETURN)______$______13- A- TOTAL OF LINES 8 THRU 12————————————— $_ 6. OTHER: (EXPLAIN)______$ B. AMOUNT FROM LINE 7______$ 14. DIFFERENCE BETWEEN LINE 13 A AND 13 B 7. TOTAL OF LINES 1 THRU 6———————————.————— $______ENTERED HERE AND ON PAGE 2. LINE 22)_____ $_ INCOME FROM PARTNERSHIPS AND ASSOCIATIONS (PARTNERSHIPS & ASSOCIATIONS) SCHEDULE A LOCATED IN CENTRAL COLLECTION COMMUNITIES, MUST FILE AS ONE ENTITY. Column 1 Column 2 . .. . Your share of Amount on which Name, Address and F^d. Ident. No. of Partnership, Associations, etc. Partnership, etc. City Tax Profits was paid LINE 27. TOTAL ON WHICH CITY TAX IS DUE(COLUMN 1 LESS COLUMN 2) (ENTER HERE AND ON PAGE 1, LINE 2).______..__ . ______.._____. .______. ______$_- INCOME FROM RENTS - IF MORE THAN ONE PROPERTY INVOLVED - GIVE COMPLETE BREAKDOWN SCHEDULE B AND ADDRESS OF EACH - JOINTLY OWNED PROPERTY MUST FILE AS ONE ENTITY. 1. 2. Amount 3. Depreciation or 4. Repairs 5.Other Expenses Location of property nf Ofnt depletion, (explain (explain In (Itemize In in Schedule B-l Schedule B-2) Schedule B-2) LINE28.. A. NET PROFIT (COLUMN 2 LESS SUM OF COLS. 3, 4, & 5)..____———.——...——..——————______.__..___ _1_ B. RENTAL LOSS PRIOR YEARS TOTAL LOSS 1967______1969______$______1968————————————————— 1970.———————————————. TOTAL $__ (IF PROPERTIES ARE LOCATED IN MORE THAN ONE COMMUNITY—SHOW BREAKDOWN BY COMMUNITY) C. NET PROFIT FROM RENTS AFTER LOSS ADJUSTMENT (ENTER HERE AND ON PAGE 1, LINE 3)______ SCHEDULE B-1 EXPLANATION OF DEDUCTIONS FOR DEPRECIATION OR DEPLETION CLAIMED IN SCHEDULE B 1. Kind of property (if buildings, state material 2 34 Depreciation 5 Method of g Rate (*) 7 of which constructed).Exclude land and Date Cost or 'allowed (or computing or life ' Depreciation other depreciable property. acquired other basis allowable) in depreciation (years) for this year prior years _$______$______. SCHEDULE B-2 EXPLANATION OF DEDUCTIONS FOR REPAIRS AND OTHER EXPENSES CLAIMED IN SCHEDULE B EXPLANATION AMOUNT Number EXPLANATION AMOUNT Page 4 SCHEDULE E TAXABLE INCOME FROM ALL OTHER SOURCES (Attach Explanation) LINE 29. A ESTATES AND TR USTS 3 B. PREVIOUS BAD DEBTS COLLECTED r OTHER D. TOTAL TAXABLE INCOME (ENTER HERE AND ON PAGE 1, LINE 5) $ I SCHEDULE G INCOME FROM WAGES, SALARIES, COMMISSIONS AND DIRECTORS FEES A. Name of Employer Address B. City Where Earned C. Income D. Tax Withheld LINE 30. TOTAL TAX WITHHELD COLUMN D-W2 OR FORM 1099 MUST BE ATTACHED FOR EACH EMPLOYER LISTED IFNTPR HFRF AND ON PARF 1 IINFRn) $ ,„ LINE 31. A TOTAL INCOME (COLUMN C! $. B. LESS DEDUCTIBLE EXPENSES ALLOWA BLE (ATTACH FORM CCA 120-15 OR FE DERAL2106) S- C. TAXABLE INCOME (LINE 31A LESS 31B) ENTER HERE AND ON PAGE 1, LITME 1 < SCHEDULE H DISTRIBUTION OF PROFITS FROM PARTNERSHIPS, ASSOCIATIONS, ETC. (If more space is required, attach schedule) DISTRIBUTIVE NAMES OF PARTNERS OR MEMBERS SOCIAL SECURITY NO. ADDRESSES SHARES OF PROFITS l TOTAL (To agree with Line 21 or Line 23, Schedule C, Page 2, if this return i $ U.S. Corporation Income Tax Return Fonw 1120 fore»l«nd»r year 1371 or ' th«r taxable ye ir beginning .....-..„..__... —— ..... 1S71, sfiriitig ...... 19 K3SP*«vle« TYPE OR DRIMT) DEnplofir ItalMcitlgn 08ITT5 CHEMICAL CC *"• 34-0420864 M? LOri^T ST PC P 375 ElSjIibiFieSnoMtid f L ^R ! A 44035 - Lorain F taHr tout OMte from Ho* 14, atom (D), Sdwlul* L (f* iiufrnc- tiM R) IMS see* sdlafJiles. tfjja lines on tfm schedule «r« no^jurfjaeni^jee Initructlon ff 1 Qrm r«M!ptt and allowance* ...... 2 Le««Co»tof (Schedule A} and/or operations (attach schedule) 200753.8 .5.8007^8. 4 DM*«nds (ScrwduNFC) ...... A..-,.. 8 Ifttertat on oblig«tlor»s of the United States and U.S. instrumentalities 5 ', 0 Older interest ...... 6 7 Qross rents ...... 8 Qross royalties ...... 9 (ft) Net c*pit*S gtlne—-{separate Schedule D) ...... |b) Ordinary gain orttess") from Part II, Form 4797 (attach Form 4797) 10 Other income (tee instructions—attach schedule) ..... 10 11 TOTAL l«com«—Add lines 3 through 10 ._. , ..... 11 ^fton7 (1« 12 Compensation of officers (Schedule t) . . . _«_.12 ...... 229J5.J5.. 13 Salaries arid wages (not deducted el< cohere) . . 13 14 Repairs (tee instructions) ...... 1Q2.2...5A ** itad debts (Schedule F if reserve method Is used). 1* Rents ...... Ji_ "31^'^dQ.' 17 Taxes (attach schedule) ...... 17 18 Interest?^. . . «.'<& ^L *» Cofltrlbutlon» (not ovw ftfi of Km 28 Mlpusted per Inatructione—attach schedule) Jil Amorti»ton (•ttae|i schedule) ...... Jl eep«*«tation (Schsdge 0) .. k '"-V ...... « Defiition , . , ;i. . ,. . . . ,i ...... 22 23 24 etc, piaa» (•«* Instructions) 27 TDTAt 3ed»|a|(ws~Add Jine» la U»ro»4gh 26 ...... _27_ |8 taxable 'ncome te»'re ittt operating Mffe iadMition and sptclal deductions IH»lin«27). '._??. .LJ.I31Q.a2) V Ut»: (ft) Net opeffcting loss deductkin|»tlns«ructlon*-attadi schedule) )j»J») less line 29)...... • :S . • . . • - . . 30 31 TOTAt TAX (Schedule JJ» . i . . . . K Gfcpetts: {*) Owrpayonot from 1970 «fk*»8d a* a andlt . (b) 1971 ettfmated tax ,p»ym«rte ..... (c) Uss refund of 1171 «stimat»d tax applied for on &rm 4481 ...... K (4^M deaosttM with Form 7IM (attach cow) ...... j...__...... I <•)Tax deposited with Rujp 7WS (attach copy) ...... '...... (f) Credit from regulated ihwajrtmenl companies (attach Form 2439) . . .j...... (I) U.S. tax on -pedal fimh, noahighway get and lubricating oil (attach Form4136V 0 .... _ Ji TAX DUE (line 31 less line 32). See instruction (3 for depositary method o* payment . . 3g_ ?na.. i 44 OVERPAYMENT (Itae 32 te«s line 31) ...... JI4 3J| Enter amount of lintM you want: Credited lo 1972 estimated tax |j»______Refunded 35 Un*r fwniMtM* e( perjury, t D«t« TillB ...... J. P. WOLT2 jb ft?- oi ) firm the rtuin ELYRIA SAVINGS & TRUST BLDG. ELYRIA, OHIO 44035 Tax Administrator's Information Release No. 1 ncome U,ax C7Tigency, JOHN R. URBAN Administrator Subsequent to the "Preliminary Information to Employers and Those Example: Any employee working in a R.I.T.A. municipality shall Paying Taxes on Net Profits" pamphlet sent out by the Regional In- be withheld on his gross compensation at that municipality's tax come Tax Agency, numerous phone calls were received. To provide rate and all of this withholding will be sent to R.I.T.A. for alloca- additional clarification, a recapitulation of these questions and the tion to that municipality. appropriate answers are included in this bulletin: 6. Question: If an employee works either all or part of his time in 1. Question: Where should the withholding be sent of municipal tax a non-taxing municipality (a municipality without an income tax withheld from an employee's wages earned in December, 1971, ordinance), should the employer withhold municipal tax from but paid on or after January 1, 1972? compensation paid the employee while he is working in the non- taxing municipality? Answer: As the wage was paid in 1972 and the municipal tax was withheld at this time (and will be reflected on the employee's Answer: To answer this question, it is important to know if this 1972 Federal W-2 Form), this withholding should be sent to the employer is doing business in the employee's city of residence. agency of the municipality for which the tax was withheld. In the a) If the employer is not doing business in the employee's city case of R.I.T.A. member municipalities, this withholding will be of residence, the employer is not required to withhold muni- sent to the Regional Income Tax Agency, P. 0. Box 6600, Cleve- cipal tax on any compensation earned by an employee in the land, Ohio 44101. non-taxing municipality. 2. Question: When are municipal income taxes withheld by an em- b) However, if the employer is doing business in the employee's ployer due and payable? city of residence, the employer shall be required to withhold Answer: Effective January 1, 1972, the ordinances of R.I.T.A. on compensation earned in the non-taxing municipality and member municipalities require that on or before the last day of allocate this portion of withholding earned in the non-taxing each month, the taxes withheld in the previous month be paid municipality to the employee's city of residence. and a return filed with the Regional Income Tax Agency. However, Example: a) If a Berea employer employs a Shaker Heights if the amount deducted in any one month for a municipality is less resident and this employer is not doing business in Shaker than $100.00, the employer may defer the filing of a return and Heights, the employer would not withhold on any compen- payment of the amount deducted until the last day of the month sation earned by the Shaker Heights employee for work per- following the end of the calendar quarter. formed in Medina (a non-taxing municipality). 3. Question: Have any R.I.T.A. member municipalities increased Example: b) However, if a Berea employer employs a Shaker their rate of municipal tax? Heights resident and this employer is doing business in Shaker Heights, the employer will withhold on all compen- Answer: No, all R.I.T.A. member municipalities have retained a tax rate of 1% except Cuyahoga Heights which has retained a sation earned by the Shaker Heights resident. He will allocate tax rate of Vfe of !%• However, many R.I.T.A. member munici- this withholding first to the municipality where the work was palities apply a reduced tax credit to the taxable income of a performed provided that municipality has a municipal income resident so that an individual is taxed both where he works and tax. If the municipality where the work was performed by the where he lives (additional local residence tax). Shaker Heights employee does not have a municipal income tax, the employer shall allocate the withholding to the city of 4. Question: Will employers be required to withhold from employees residence, namely, Shaker Heights. the reduced tax credit also known as the additional local residence tax? 7. Question: What if an employer has employees working in more than one municipality and these municipalities are not all R.I.T.A. Answer: No, the responsibiltiy of paying the reduced tax credit members, where should the withholding be sent? (additional local residence tax) falls on the employee and not the employer. The employer shall only be required to withhold the Answer: a) The municipal tax due from compensation earned tax rate of the municipality where the work was performed. (See by an employee in any one of the 41 R.I.T.A. municipalities shall also question 6). be sent to the Regional Income Tax Agency. 5. Question: To what municipality shall the employer allocate the b) The municipal tax due from compensation earned municipal tax withheld from compensation paid an employee? by an employee in any one of the Central Collection Agency municipalities shall be sent to the Central Collection Agency. Answer: The withheld municipal tax shall be allocated to the municipality where the work was performed by the employee. In c) The municipal tax due from compensation earned case of municipal tax due R.I.T.A. municipalities, this withheld by an employee in any taxing municipality other than those be- tax will be sent to the Regional Income Tax Agency. (See also longing to R.I.T.A. or C.C.A. should be sent directly to that muni- question 6) cipality. For your convenience, a list of the R.I.T.A., C.C.A. and indepen- dent municipalities in the proximity of Cleveland are included at the end of this pamphlet. 8. Question: In the case where employees are moving about con- stantly, municipality to municipality, where shall the employer al- locate the withholding? Answer: In the case of this type of activity by the employee, the employer should present a formula for allocating this with- holding to the Administrator for approval. However, the employer shall be responsible for any material error in allocation. MUNICIPALITIES BELONGING TO THE REGIONAL INCOME TAX AGENCY 1. Aurora 15. Highland Heights 29. Pepper Pike 2. Bay Village 16. Independence 30. Richmond Heights 3. Bedford 17. Lakewood 31. Seven Hills 4. Bentleyville 18. Lyndhurst 32. Shaker Heights 5. Berea 19. Maple Heights 33. Sheffield 6. Brecksville 20. Mayfield Heights 34. South Euclid 7. Broadview Heights 21. Mayfield 35. Streetsboro 8. Brooklyn Heights 22. Middleburg Heights 36. Strongsville 9. Chagrin Falls 23. Moreland Hills 37. University Heights 10. Cleveland Heights 24. Newburgh Heights 38. Valley View 11. Cuyahoga Heights 25. North Olmsted 39. Walton Hills 12. Elyria 26. Oakwood 40. Westlake 13. Fairview Park 27. Olmsted Falls 41. Woodmere 14. Garfield Heights 28. Orange C.C.A. MEMBER MUNICIPALITIES 1. Bratenahl 9. Hunting Valley 17. South Russell 2. Burton 10. Kirtland 18. Timberlake 3. Chardon 11. Linndale 19. Warrensville Heights 4. Cleveland 12. Mentor 20. Wickliffe 5. East Cleveland 13. Mentor on the Lake 21. Willoughby 6. Eastlake 14. Middlefield 22. Willoughby Hills 7. Euclid 15. Northfield 23. Willowick 8. Gates Mills 16. North Randall INDEPENDENT MUNICIPALITIES 1. Avon 7. Fairlawn 13. Richfield 2. Avon Lake 8. Lorain 14. Rocky River 3. Bedford Heights 9. North Ridgeville 15. Sheffield Lake 4. Brooklyn 10. North Royalton 16. Solon 5. Brook Park 11. Parma 17. Twinsburg 6. Brunswick 12. Parma Heights 18. Vermilion Preliminary Information To Employers And Those Paying Taxes On Net Profits ncome ax • C?Tigency, JOHN R. URBAN Administrator On June 11, 1971, the Regional Income Tax Agency (R.I.T.A.) the employer may defer the filing of a return and payment of the was formed for the purpose of collecting City Income Tax for amount deducted until the last day of the month following the end certain municipalities. On the last page of this information report of the calendar quarter in which such month occurred. is a list of 41 municipalities participating in the agency. Most of Withholding after January 1, 1972, is designed to be simpler. the actual changes affecting you will take place on January 1, 1972, Generally, taxes are to be withheld based upon the tax levied by and this letter is to provide you with preliminary information so the municipality or municipalities where the employee works and that you may make necessary adjustments in your accounting and there is no requirement to make any allowance for reciprocity to withholding procedures. the community where the employee resides. For example, under As the 41 municipalities which now constitute R.I.T.A. have been the old reciprocity allocation method of filing, if you withheld and will be members of the Central Collection Agency (C.C.A.) $100.00 for an employee living in Cleveland and working in Shaker through December 31, 1971, the following procedures should be Heights, $75.00 was allocated to Shaker Heights and $25.00 was followed: allocated to Cleveland. Under the new procedure, the entire $100.00 will be allocated to the workplace, Shaker Heights. For All 1971 Taxes Due: 1. Taxes Withheld on all payrolls through December 31, 1971, There is an exception to the above rule which requires withhold- together with the final report of withholding on form CCA-120-11 ing in certain instances based upon the tax of an employee's resi- (CCA-W3) due to the municipalities listed on the last page shall dence community. For example, where a Berea resident earns be reported and paid to C.C.A. $10,000, and works in a non-taxing community and his employer is doing business in Berea, a member of R.I.T.A., the employer 2. Net Profits of calendar year taxpayers for the year 1971 would withhold $100.00 and allocate the entire $100.00 to Berea. shall be reported on the appropriate C.C.A. forms and the tax paid to C.C.A. Please bear in mind that the municipalities participating in 3. Net Profits of fiscal year taxpayers whose year started before R.I.T.A. will continue to negotiate for a single metropolitan-wide January 1, 1972, will continue to report on returns and make agency for the convenience of all taxpayers. In the meantime, com- payments to C.C.A. for that fiscal year which ends prior to pliance with the requirements of the members of R.I.T.A. does not December 31, 1972, and subsequently instructions in paragraph relieve you of the responsibility for filing and making payments to four apply. the Central Collection Agency or other non-central municipalities whenever you have withholding taxes or net profits due to the other For All 1972 Taxes Due: municipalities. 4. Net Profits of calendar year taxpayers for year 1972, and We will send you additional information as it develops. We will for fiscal year taxpayers whose year begins on or after January do our best to answer your inquiries at the telephone number listed 1, 1972, due to the municipalities listed on the last page shall below, and we expect to provide you with new R.I.T.A. withholding be paid to R.I.T.A. as well as the quarterly estimate of those net tax forms and instructions around December 20, 1971. profits. 5. Taxes Withheld from employee's payroll commencing January Payments and returns required to be filed with C.C.A. should be 1, 1972, and thereafter, due to the municipalities listed on the sent to: DIVISION OF TAXATION Telephone Number last page shall be filed with R.I.T.A. (See Comments below.) 1701 LAKESIDE AVENUE, N. E. 694-2070 The tax ordinances of the communities listed on the last page CLEVELAND, OHIO 44114 require compliance with the above numbered paragraphs. Effective Payments and returns required to be filed with R.I.T.A. should January 1, 1972, these same ordinances require that on or before be sent to: the last day of each month the taxes withheld in the previous month R. I. T. A. Telephone Number be paid and a return filed with R.I.T.A. However, if the amount P. 0. BOX 6600 398-2730 deducted in any one month for a municipality is less than $100.00, CLEVELAND, OHIO 44101 MUNICIPALITIES BELONGING TO THE REGIONAL INCOME TAX AGENCY Municipality Municipality CITY OF AURORA VILLAGE OF MAYFIELD HEIGHTS CITY OF BAY VILLAGE CITY OF MIDDLEBURG HEIGHTS CITY OF BEDFORD VILLAGE OF MORELAND HILLS VILLAGE OF BENTLEYVILLE VILLAGE OF NEWBURG HEIGHTS CITY OF BEREA CITY OF NORTH OLMSTED CITY OF BRECKSVILLE VILLAGE OF OAKWOOD CITY OF BROADVIEW HEIGHTS VILLAGE OF OLMSTED FALLS CITY OF BROOKLYN HEIGHTS VILLAGE OF ORANGE VILLAGE OF CHAGRIN FALLS VILLAGE OF PEPPER PIKE CITY OF CLEVELAND HEIGHTS CITY OF RICHMOND HEIGHTS VILLAGE OF CUYAHOGA HEIGHTS CITY OF SEVEN HILLS CITY OF ELYRIA CITY OF SHAKER HEIGHTS CITY OF FAIR VIEW PARK VILLAGE OF SHEFFIELD CITY OF GARFIELD HEIGHTS CITY OF SOUTH EUCLID VILLAGE OF HIGHLAND HEIGHTS CITY OF STREETSBORO CITY OF INDEPENDENCE CITY OF STRONGSVILLE CITY OF LAKEWOOD CITY OF UNIVERSITY HEIGHTS CITY OF LYNDHURST VILLAGE OF VALLEY VIEW CITY OF MAPLE HEIGHTS VILLAGE OF WALTON HILLS CITY OF MAYFIELD HEIGHTS CITY OF WESTLAKE VILLAGE OF WOODMERE IHJTffi.AIL IMPORT AN T NOTICE WITHHOLDING MUNICIPAL INCOME TAXES GOVERNMENTAL EMPLOYERS: House Bill 108 requires the State of Ohio and its political subdivisions (County, School Boards, Libraries, etc. ) to withhold municipal income taxes from wages of public employees. This bill eliminates the requirement of securing the employees authorization in order to withhold city tax and therefore places these employers in the same category as private industry. The effective date of the law is December 27, 1971, and thereafter, local municipal taxes must be withheld from the wages earned in a taxing municipality. Further information concerning this change in the law can be secured from State Director of Finance, Columbus, Ohio, as -well as from the Collection Agencies specified below. CANCELLING RECIPROCITY: Effective January 1, 1972, the taxing municipalities listed on the 4th quarter return for 1971, have cancelled reciprocity. The possible exception to this is the City of Elyria. Further information can be secured from officials of that City concerning this matter. The effect of reciprocity means that no longer will you as an employer, be required to allocate 75% of the tax withheld to the community of employment and the balance of 25% to the resident community of the employees. All taxes withheld beginning with January 1, 1972, will be held and reported to the community of employment. Further information concerning the reporting method will be forwarded to you by the Collection Agency that the municipalities have contracted to be a member of. COLLECTION AGENCIES: Effective January 1, 1972, a number of municipalities presently ro-ftmivt-i•& ui Vne Central Collection Agenev.-, wJA'ccfct-urne members of a new collection agency -- "Regional Income Tax Agency" (RITA). All returns pertaining to calendar year 1971, as well as fiscal years ending in 1972, are to be filed with the Central Collection Agency. Calendar year 1972, and fiscal year taxpayers beginning in 1972, are to file with the agency that the municipalities are members of. CENTRAL COLLECTION AGENCY 1701 Lakeside Avenue Cleveland, Ohio 44114 Area Code 216-694-2070 Brstenahl Euclid Mentor Timber lake Chardon Gates Mills Mentor -on-the-Lake Warrensville Heights Cleveland Hunting Valley Northfield Wickliffe East Cleveland Kirtland Middlefield Willoughby Eastlake Linndale North Randall Willoughby Hills South Russell Willowick R. I. T. A. P. O. Box 6600 Cleveland, Ohio 44101 Area Code 216-398-2730 Aurora Garfield Heights Orange Bay Village Highland Heights Pepper Pike Bedford Independence Richmond Heights Bentleyville Lake wood Seven Hills Berea Lyndhurst Shaker Heights Breaks ville Maple Heights Sheffield Village Broadview Heights Mayfield Heights South Euclid Brooklyn Heights May field Village Streetsboro Chagrin Falls Middleburg Heights Stongsville Cleveland Heights Moreland Hills University Heights Cuyahoga Heights Newburg Heights Valley View Elyria North Olmsted Walton Hills Fairview Park Oakwood Westlake Olmsted Falls Woodmere The City of Beachwood will collect its own tax, effective January 1, 1972. CITY OF BEACHWOOD Income Tax Division 25511 Fairmount Boulevard Beachwood, Ohio 44124 Area Code 216-464-1070 Further information can be secured by calling any of the phone numbers listed above. CENTRAL COLLECTION AGENCY EMPLOYER'S QUARTERLY MUNICIPAL TAX RETURN If 'Final R«tum" CENTRAL COLLECTION AGENCY/), Indicate here ...... DIVISION OF TAXATION Date Quarter Ended J Employer 10 No. Date Due Total w*gw subject to DEC. 31, 1971 JAN. 31, 1972 r ft! am* 2. Amount of tax withheld ...... $ 28*.\j 7r . \jrfT 3. Adjustment for preceding ^ Trade Name, If any quarters of calendar year 3 (PLEABE 0 4. Adjusted total of tax withheld . . $ 287,6$ 5. Total of enaotad depositary mcalpti (MW other side) .....,...$. *. Balanoa due and pakl herewith {Itam 4 mint* Itam 5) ...... $. *fc SUKe TO iNClOSt; REMITTANCE AMD DEPOSITARY RECEIPTS WITH THIS RETURN MUNICIPALITY I ' j CODE j £MPLOYNB2NT ] RESIDENCE - MUNICIPALITY * CODE EMPLOYMENT RESIDF MCE • 1% TAX COMMUNITIES rf f- North Olmsted 7 1-68 550 Auro-a J M-69 1 010 North Randali M-68 560 '.•* Bay. Vi]|ac|e_ 7-1 -(=8 - 040 Oakwood 7-1-68 580 Beatr wood : 7-1 G8 j 050 Olmsted Falls "'-1-69 590 Bedford 7- 168 1 OiiO Oraiige 1 1-68 600 M t;« I oeo Pepper Pike 7-1-68 ———DO I ————u ~ Bere M H! [ 100 I Richmond Hts. 7-1-68 Bratrniahl "" M /U ! 120 F Seven Hills 7-1-68 720 "f——— ———— Bred ^ille f Shaker Hts. 7-1-68 750_ JJ.rq.au ,'ievvHjs,. u;-1 tlu M40 I Sheffield Vil. 7 1-68 752 Brook '/n Hts. 10-1 -63 jTeo- 1 South Euclid 7-1-68 1 770 n C»i3fl Highland Hts. 7-i-ea ; 3?o Willouqhbf vr ..Hill. - s...... 10-1-68 880 Hunting; Valley. 1-1 S9 j_ 380 -----t-— 4 Willowick 7-1-68 890 Independence j 1-1 -6f» i 390 Woodrnere 7-1-68 900 Kirtlani; 7-1-69 i 394 1/2% TAX COMMUNITIES Kirtland Hills 4-''-71 T 396 Cuvahoqa Hts. j 1-1-71 250 I Lakswood 7-1-68 ! 400 j Middlefield 4 1-69 510 JJnndji- .._...._. ...il:j;70. ...420. ... 1...... __ . J NON CENTRAL COLLECTION Lyndhi:.rt : M-68 440 I TAXING COMMUNITIES Maple h--s. i 7-1-68 460 1 Brooklyn 7-1-68 150 BHB Mayfield Hts. 7-1-68 480 | Lorain 10-1-68 f tHB Mjynei- Vill. .7:1:68 .. 485 570 1 ^^B Men;;; 1-1 -b9 ; 490 i Parma i 7 1-68 620 HMj Mentor c i the-Lake 1-1-69 49S ...... ,. ..„.„.__._ .. Parma Hts. 7-1-68 630 SSBHa^K VtiddleLi.pflHts. 7-1 68 500 ...... ,,...... Rocky. River 7-1-68 700 •Wofelanti Hjll^ _J.1J:68 ..; 5JO f\lewburu,« Hts. i 7-1-68 540 j OTHER (ATTA CH LIST I 999 ^8!ll!f.ie|--i__.._.._.JlQrl:68 .5.4.5. : .. Denotes .irrent effective dart* at Tax Rat'-. imtfted this return and to the best of my t ^c-wledafl, it is correct. • ORM i-i jo;> 4 HEVisfeu. 'UG.1971 Da;Bn. tSt l :.i (Ownei, - rA Do you expect to pay Taxable Wages in the future? [ "] Yes j_] No If No, write "Final Return" in space provided on the front of this return. Fnter dafe of final payment of taxable wages 19 Requirements for Monthly Deposits - Every employer who is liable for more than $100.00 income tax withheld, fo. a month, is required to deposit such taxes within 20 days offer the close of such month to the Division of Taxation. Deposits for the third month of any quarter is not required as the amount due can be filed with the quarterly report. DEPOSITARY RECEIPT RECORD RECEIPT SERIAL NO. DATE OF DEPOSIT AMOUNT ...... _ .__._ . . . _ ...... This must be used by employers required to make deposits of taxes re-portable on this return. Each deposit should be accompanied by a Receipt Form EM 1 which will be validated by the Division of ...... _..... ——— . —— Taxation and returned to the employer. Validated I£f eipts -Lh0.0\A _k ? ll ?ted here and must be enclosed ...... _..__ witK this retufn. fUfAL OF ALL ENCLOSED DEPOSITARY RECEIPTS 'ENTER IN ITEM SON OTHER SIDE) GENERAL INSTRUCTIONS FOR FORM CCA-102 The instructions below relate to the preparing and filing of Form CCA-102, arid is used tt>( si? reporting of municipal income tax withheld from wages. Who Must File — If you have one or more employees you must make a return for the first quarter m Aj'ich you'are 'required to withhold municipal income tax from wages and for each quarter thereafter. If you temporarily discontinue paying wages (for e; ample, seasonal work), you must nevertheless file retu ns If you no longer expect to pay wages subject to the tax re|;ortable on this form you must file a "Final Return". After you hove once filed a return, a pre-addressed Form CCA-102 will be mailed to you every thirty; (3) months If rne form should fail to reach you request a Form CCA-102 so that you can file your return on time. Transfer or Sale of Business — If a business is transfeired or sold by one employer to another, each employer must filf a separate return. Quarterly Returns and Due Dates - A return must be filed for each quarter of the calendar year as follows QUARTER COVERED QUARTER ENDING DUE ON OR BEFORE January, February, March Marcn 31st April 30th Apri I, May, June June 30th July 31st July, August, September September 30th October 31st Octobe , November, December December 31st Jartuary 31st Where To File - Taxpayers whose business places are located the commun'ties shown on ihe front of this rerun are required to file their return with the Division of Taxation, 1701 Lakeside Avenue, Cleveland, Ohio 44114 Payment of Tax - Each return Form CCA-102 should be accompanied by the remittance (check, money order, depositary receipt or combination of these) for the total taxes reported in Item 6. Employer Identification Number, Name and Address - Prt--addressed Form CCA-102 should be used in filing returns If pre-oddressed form is lost, request another and type 01 print in the name, address, identification number i.-icludinti all other pertinent information. If you do not have a number, indicate on the return and a Division of Taxation numbei wi. I be ass igned to you. Penalties and Interest — The law provides penalties for !ate filing of a return and payments thereof A uid penalties one interest by filing returns and payments of tax. Penalties also are imposed by law for willful failure to pay collect or truthfully account for and pay over tax. keep record-;, make returns, for false or fraudulent returns, or for submitting bad checks. FORMS W-2 AND CCA-W3 When filing return on CCA-102 for the last quai ter of the calendar year or when filing final return if final wages are paid before the end of the year the employe, must transmit copies (W-2) of all wages and lax statements issued for the yeor tooether with a Form W-3, Reconci Mat-on of Income Tax withheld. Form CCA-W3 will be mailed with return for the fourth quarter. If a final return is filed before the end of the year, Form CCA-W3 should be requested from Division of Taxation. Instructions for Form CCA-A3 are printed on the back of said form. SPECIFIC INSTRUCTIONS Item 1 - Enter only the total taxable wages paid to employees, o not include wages (paid thai ire) earned taxing communities not listed on the front of this return. Item 2 - Enter in Item 2 the amount of income tax withheld on wages. Item 3 — Adjustment of Income Tax Withheld. Item 3 should be used for the correction of errors made m connection with the withholding of income tax from wages paid in the preceding quarters of the same calendar year. Any amount in Item 3 must be explained by a statement enclosed with the return. The statement must set forth: (a) Explanation of the error which is intended to be corrected; (b) The particular return period or periods to which the error relates; (c) The amount chargeable to each such period; and (d) The manner in which the error has been settled. Item 4 - Adjusted Total Income Tax Withheld. This amount should either be the total or the difference ot Items 2 and 3 depending on whether the items are added or subtracted. Item 6 - Trie amount indicated in this column must be paid not later than one month following the close oi the quarter. XI XI Ci Nj O <2 O\ Xj O\ ***O I I I I I I I -•* Oi NJ -fc O O\ i I I I I Os Vjj XI C5 XJ VA> V^i NJ "- ° VAJ O^ o O\ 35 J?> S^J ^IOk gre flpj>- l ^ .^.^ .^ ^^ •fr*- 5Hll XI -fe Vji ,U* >so V^i • » Ci 0\ a Os O XI •** O\ isj XI -15. Oo -fc. OQ VM o\ Vju Oo XI HS. "vj Ci O\ £T\ ^ ie * i -t V* ' VL ^ I M^ ^I «>'\>* f *ri ff « f * ^?^^ iu. v. p» X k ^ > * ^> ^\- a g o* vj Ti PROFIT RETURN DECLARATION OF ESTIMATED MUNICIPAL INCOME TAX CENTRAL COLLECTION AGENCY 1971 DIVISION OF TAXATION FOR CALENDAR YEAR 1971 wn I IUWRL. i L-nn « «-un«i«i «i «• „.. — ———— ., ,_.... ._.... - _. - - - ... ? CMECK WHICH: OWNER PROFESSIONAL PARTNERSHIP CORPORATION OTHER .. __ &TATUS: RESIDENT r NOW HtSIOENT TYPE OF INCOME: RENTAL BUSINESS OTHER., QUARTER FEDERAL OR f-CCi DATE DUE SECURITY NUMBF. R DEC . 3 1 . 1971 1. TAX PREVIOUSLY ... , 4TH ESTIMATED...... 1 dO fit PRINT NAME 2 ESTIMATED TAX ADJUSTED. . ,,,.,--- * -.- . (SEE INSTRUCTIONS) w OfattAA (kejru.caJ. (Company. TRADE NAME, IF ANY .>j:g. 0. 3. ADJUSTED ESTIMATED TAX (LINE 1 PLUS OR MINUS » in", rtt at BUSINESS ADDRE^it ., ' ' LINE 2)...... o * 9M2 LdmtfAjt 'M^&&A -P.0if BQX Wf$ 4. PRIOR PAYMENTS MADE . . , - , -,,.*.- r $ If) (H X : : CJTY AND "ZIP CODE' 1;;.«. ^ '••-."• " ' ;•' • •• ' '•• -^' F : to, S. UNPAID BALANCE „ 10. Ot RESIDENT ADDRESS (LINE 3 LESS LINE < f 3 6. AMOUNT PAID WITH THIS RETURN \ .j CITY AND ZIP CODE : (THE AMOUNT SHOW N ON LINE 5 . 1 ,- ,-,, \ &. SHOULD BE PAID! \ IVlS/d MUNICIPALITY fy l.CODEJ AMOUNT MUNICIPALITY # CODE AMOUNT i "/.TA. X COMMUNITIES Newburqh Hts. 7-1-68 540 ; t orj_____ „ ___ . _ . .. _ M-159 irsii • Northfield 10-1-68 545 1 fiay Villaqe 7-1-68.1 040 i T North Olmsted 7-1-68 550 1 BJM chwood j. 7-1-68 !: 050 j ~T North Randall 7-1-68 560 r IfiS ford 7-1-68 ' 060 Oakwood 7-1-68 580 Bin tisyville M-69- " 9)G ~^" Olmsted Falls 1-1-69 rB90 B(! 83 7-1-88 fiid ' ' r Orange 7-1-68 600 • Biatenahl 1 7-1-70 120 I Pepper Pike 7-1-68 650 Brt ;ksviile 1-1.69 CiC \ \ Richmond Hts. 7-1-68 670 Bifiadview Hts. 1-1-69 140 i __ Seven Hills 7-1-68 720 i qkjYnJJls, 10-1-68 160 ^ Shaker Hts. 7- -68 750 Chagrin Falls 7-1-68 180 Sheffield Vil. 7- -68 752 i Cfor rdort 1-1-70 } 185 '* ^ South Euclid 7- -68 770 CI'B'/eiand 7-l-6i! ?00 _ * South Russell 1- -69 772 Cle •eland Hts. _ 1 7-1-66 i 2«0 | ,__Streetsbor_ o 1- -69 775 i Eas Cleveland j 7- 1-68 T 270 ' Strongsville 7- -68 780 Eastlake 1-1 -69 T 273 T ! Timberlake 10-1-68 788 j li¥ ia 8-1 -69 277 j J_ University Hts. 7-1-68" 800 _j_ Eu, 'id ' 7-1-68 280 l Valley View ! 1-1-69 810 • Far view Park 7-1-68 300 [ ^ Walton Hills 1 4 1-69 820 Gar leldHts. i 7-1-68 320 ; ^ Warrensville Hts. 7-1-68 830 I Gatfis Mills 7-1-88 * .330 Westiake 7-1-68 840 Hi,, iland Hts. 7-1 -88 ; 3?Ci I Wickliffe 7-1-69 860 I Huj ting Valley 1-1-69 T 380 , ! Willoughby 1-1-69 870 Ind sjjendence 1-1 -B9 390 ! Willoughbv Hills 10-L68J 880 j__ Kin and 7-1-69 3S4 ____Willowic_k 7-1-68 890 Kin and Hills 4-1-71 1 395 ____Woodmer_e 7-1-68 900 ! Lakawood 7-1-68 400 j ____1/2%_ TAX COMMUNITY Lirmdale 7-1-70 420 CuvahoqaHts. 1-1-71 I 250 j Lyndhurst 7-1-68 440 ! ' Middlefield | 4-1-69 I 510 I < Mapie Hts. 7-1-68 460 ' TOTAL - ALL LOCATIONS • r Mayfield Hts. 7-1 68 ! 480 T " Ma^fiejd Vilj. ______]_ 7-1 B8 \ 485 I 1 have examined this declaration and to the best of my knowledge Mentor _ |_ M 69 j 490 i ' it is correct, Mentor-on-the-Lake j_ 1-1 69 ! 495 ___ Middleburg Hts. '' 7-1-68 i :>00 . Moreland Hills ! 7-1-68 >' h£:J 72-47-7; * Denotes current effective date of tax rale AUTHORIZED SIGNATURE DATE H-4 REVISED AUG. GENERAL INSTRUCTIONS Ittm 1 - Purpose of Declaration - The purpose of the Declaration is to enable certain taxpayers as specified below, to estimate their taxable income and to provide a basis for paying the tax quarterly- Such taxpayers must also file an annual return of actual taxable income and pay any balance of tax due. Item 2 - Who need not make a Declaration - You need not make a Declaration or a Final Return, if your income consists solely of salaries, wages, etc. from which an employer(s) withholds the municipal income tax from the gross amount of such income for anyone of the com- munities under the Central Collection Agency. Item 3 • Who must make a Declaration (Form CCA '^Q 201-ES)- Except as provided in the preceding paragraph, a Declaration must be maoe by the following: (a) Every resident of a municipality under Central Collection Agency who expects income during the taxable year from rental property and for other sources wherever such property or other source is located. The net amount of such income is taxable. (b) Every non-resident of a taxing comrr unity in central collection who expects to earn income during the taxable year from rental property and/^r other sources located within said taxing community under central collection. (c) Every resident business or professional entity including individual proprietorships, associations and other entities which expect a net profit for the taxable year. (d) Every non-resident business or professional entity including individual proprietorships, partnerships, associations and other entities which expect a profit derived from business transacted, work done, services performed or any other activity conducted in a taxing municipality under the Central Collection Agency during the taxable year. (e) Every corporation which expects to ealize a profit derived from business transacted, work done, services performed or any other activity conducted in a taxing community under the Central Collection .Agency during the taxable year, whether or not such corporation has an office or place of .business, located in said taxing community. Item 4 - In the Case of any Resident Unincorporated Business or Professional Entity - owned by two or more persons, the tax imposed by the Ordinance shall be levied against the business entity rather than the individual owners or partners. Resident partners, of a non-resident unincorporated business are taxed individually on such part of their distributive shares of the business income as has not been taxed to the business entity. Ittm 5 - Net Profit - The net gain from the operation of a business profession, enterprise or other activity after provision for all ordinary and necessary expenses, either paid or accrued in accordance with the accounting system used by the taxpayer for Federal Income Tax pur- poses, without deduction of taxes imposed by the ordinance, federal, state and other taxes based on income; and in the case of ;in association, without deduction of salaries paid to partners and other owners; and otherwise adjusted to the requirements of the Ordinance. Item 6 - Where and When to File a Declaration - (a) Declarations should be mailed or delivered to the Division of Taxation, 1701 Lakeside Avenue, Cleveland, Ohio 44114. (b) Calendar Year Taxpayers must file on or before April 30th. The second, third and fourth payments are due on June 30th, September 30th and December 31st. Taxpayers of communi- ties joining Central Collection Agency and not previously subject to paying the tax, shall file a Declaration within 120 days of the date they become subject to the tax. Thereafter, the taxpayer shall file in the same manner as other calendar taxpayers. (c) Taxpayers On Fiscal Year Basis - shall make their Declaration and subsequent quarterly installments on the same basis as other taxpayers, except that the calendar quarters of the fiscal year taxpayers shall be adjusted in accordance with the specific fiscal year. For example, the four installment payment dates of a fiscal year beginning February 1st, would be: 1st poyment, May 31st; 2nd, July 31st; 3rd, October 31st; and 4th and final payment, January 31st PROFIT RETURN DECLARATION OF ESTIMATED MUNICIPAL INCOME TAX CENTRAL COLLECTION AGENCY 1971 DIVISION OF TAXATION FOR CALENDAR YEAR 1971 OR FISCAL YEAR BEGINNING ______—————. ENDING -. c /~v u/ui i /~M. nu/uc1 o PROFESSIONAL PARTNERSHIP CORPORATION OTHER tATIIS- RESIDENT NON RESIDENT TYPE OF INCOME RENTAL BUSINESS OTHER QUARTER FEDERAL OR SOCIAL DATE DUE 1. TAX PREVIOUSLY 3RD SECURITY NUMBER SEPT. .30, 1971 ESTIMATED...... $ 2. ESTIMATED TAX ADJUSTED...... $ (SEE INSTRUCTIONS) 3. ADJUSTED ESTIMATED TAX (LINE 1 PLUS OR MINUS at \ BUSINESS ADDRESS LINE 2)...... $ O PRIOR PAYMENTS MADE. z i CITY AN_ 5. UNPAID BALANCE £i__/ (LINE 3 LESS LINE 4)...... J Ul i RESIOEIW. 20.10C 1/1 < 6. AMOUNT PAID WITH THIS RETURN Ul -I ; CITV ANO ZIP CODE (NOT LESS THAN 1/2 OF LINE 5) ...... $ in \nt MUNICIPALITY CODE AMOUNT MUNICIPALITY CODE AMOUNT -r Newburgh Hts. 7-1-68 540. Amora 010 i 1 Northfield 10-1-68 545 Bav Village 7-1-68 L 040 ] North Oln 550 Bec'Chwood 7-1-68 050 j 1 North Par 7-1-68 ...560. BEI '?ord 7-1-68 060 Oakwood 7-1-68 ..580 Be;iile./ville ""i-vBs" 090 ! Olmsted F 590 1 Ber;-a L 7-1-68 100 Orange 7-1-68 600 Bra:anahl ^LRO^ 120 _____ ._. •. Pepper P\[ 7-1-68 .650 Bracksville 130 Richmond 7-1-68 .670 i Br.hidview Hts. 1-1-69 140 Seven Hill .7.20 Brooklyn Hts. 10-1-68 !60. _ • Shaker Ht 7-1-68 7.50 "O . Chcijrin Falls Sheffield > 7-1-68 __ •_-^_.__.L.__ Cha don 1-1-70 1 South Euc 7-1-E H _.770_j_ Cleiviiland 7-1-68 n South Rus 1-1-69 * Cleveland Hts. ' 7-1-68 210 Streetsbor 1-1-69 .775. Easv Cleveland 7-1-68 270 j • Strongsyil 7-1-68 780. — -3—— — Ea:r :ake •1-1-69 273 • Timberlak 10-1-68 • 788. Elviia 8-1-69 _.217.. University _Z.168_ 80P_ "7-1-B8 ..._?8Q_.. ., ———— — ,— Valley Vie 1-1-69 8.10. Fail -iew Park 300 Walton Hi 4 1-69 i 820_ 3ai"ield Hts. 7-1-68 320 H Warrensvi 7-1-68 830_ Gaws Mills 7-1-68 .330 i Westlake 7-1 68 840 i Highland Hts. 7-1-68 370 • Wickliffe 7-1-69 -8.6Q_ t Hinting Valley 1-1-69 380 i Willouflhb 1-1-69 _8.7P_ i Independence 1-1-69 390 — .__._. (i ___ Willoughb 10-1-68 Kin md 7-1-69 394 Willowick 7-1-68 -890_ i Kirl ind Hills 4-1-71 395 i Woodmer. 7-1-68 900 Lakuwood 7-1-68 400 • 1/2% TA Lini iale 7-1-70 420 j • Cuyahoga 1-1-71 -250. l.ynrhurst 7-1-68 440 i Middlefiel 4-1-69 510 Maj) ti Hts. _____ ..7:168._46p__. . • TOTAL 10 \ CO May ield Hts. 480 • May ield Vill. 7-1-68 485 1 have exa to the best of my knowledge. Men ..tr 1-1-69 490 • it is correc Vlerr jr-on-the-Lake 1-1-69 495 Midi: ieburq Hts. 7-1-68 500 i Mort land Hills 7-1-68 520 • Dl: current effective date of tax rale AUTHORIZED SIGNATURE DATE FO'-: M CCA 201-3 REVISED AUG. 1971 HARRY J. P. WOLTZ, CERTIFIED PUBLIC ACCOUNTANT, ELYRIA, OHIO INSTRUCTIONS FOR FILING ATTACHED RETURN Make check for $___ / !? • ^ In payment of: Payable to: F.I.C.A. & Withholding Tax ____Internal Revenue Service Federal Income Tax ___Treasurer, ______County _Federal Estimated Income Tax______Bureau Of Employment Services _State Unemployment Tax ^Treasurer, State Of Ohio _Federal Unemployment Tax _Central Collection Agency _Deposit For Withheld Taxes 0ther _Workmen's Compensation Insurance _Sales Tax _. , .p. nr t _PersonaI Property-Bus i ness-Persona I Refund Due Of $ _Franchise Tax & Security Valuation MaiT to: _City Income Tax______Internal Revenue Service ~^_C~ity Estimated I ncome Tax Cincinnati, Ohio 45298 Other ____Enclosed envelope _Auditor, County Be sure repor^is dated and signed by: 'j^ 'Centra I Collection Agency Deposit or Wail before ~7 J 1701 Lakeside, Cleveland, Ohio 44114 Other Copy enclosed for your records IMPORTANT: To avoid penalty charges sign and mail report on or before due date even though you do not send the money. f _ __ , __ _ ^ .^. -,, PROFIT RETURN w, DECLARATION OF ESTIMATED MUNICIPAL CENTRAL COLLECTION AGENCY 1971 DIVISION OF TAXATION FOR CALENDAR YEAR 1971 ENDING CHECK WHICH: OWNER PFJOFESSIONAL PARTNERSHIP CORPORATION OTHER STATUS- RESIDENT NON RESIDENT TYPE OF INCOME: RENTAL BUSINESS OTHER QUARTER FEDERAL OR SOCIAL DATE DUE SECURITY NUMBER J. ESTIMATED ANNUAL TAXABLE NET PROFIT .. . ..-.—— .—...— ...... S ^AAA J* ' PRINT NAME 2. ESTIMATED ANNUAL TAX (MULTIPLY w Ohl'H'Q Chamlcnl Cnmn»n\/ NET PROFIT X RATE EFFECTIVE IN ^ f *****»•- ' BUSINESS COMMUrM l' 1 'Y)... " ...... " -4 > ———————————————'fUjpt " "J it 11 Bu4 3. LESS AMOUNT OF OVERPAYMENT ON YOUR 1970 INCOME TAX RETURN AND * %jf TJJL CREDITED AGAINS T YOUR 1971 EST1- ^ S"frr»a^fr -iiii- fl. Ji — MATED TAX...... Z CITY A|i|: ZIP COlfli. at iff iMf,. iff fl ^ B 4. NET ESTIMATED TAX DUE o- ifclvrla «ll 3) « An*.n W ' RESIDJIPA&WIS* ™ "H! (LINE Z LESS LINE V) ————————————————— ' 5. AMOUNT PAID WITH THIS RETiUR . N AIK J CITY AND ZIP CODE (NOT LESS THAN 1/4 OF LINE^ 0. jfli!|' :'fs>'i>; lOdO i '" •*&••' 5 Ml, MUNICIPALITY j^s * Hhrf ! fcODE f AMOUNT MUNICIPALITY * CODE AMOUNT iyD TAX COMMUNITIES North Olmsted 7-1-68 550 Aurora 1-1-69 010 North Randall 7-1-68 560 gay Village 7-1-68 040 Oakwood 7-1-68 580 Ipaqhwaqd 7-1-68 flfifl Olmsted Falls 1-1-69 590 ifdfmd 7-1-68 —CfiJL. Orange 7-1-68 600 jjpntleyviJIe 1-1-69 090 Pepper Pike 7-1-68 650 if reei 7-1-68 100 Richmond Hts. 7-1-68 670 Qfatenahl 7-1-70 120 Seven Hills 7-1-68 720 %ecksville 1-1-69 130 Shaker Hts. 7-1-68 750 Ifoadview Hts. 1-1-69 140 Sheffield Vil. 7-1-68 752 %ooklvn Hts. 10-1-68 160 South Euclid 7-1-68 770 Jhaqrin Falls 7-1-68 180 South Russell 1-1-69 772 IJhardon 1-1-70 185 Streetsboro 1-1-69 775 Jjeveland 7-1-68 200 Stronpsville 7-1-68 780 Cjeveland Hts. 7-1-68 210 Timberlake 10-1-68 788 Ejist Cleveland 7-1-68 270 University Hts. 7-1-68 800 Ustlake 1-1-69 273 Valley View 1-1-69 810 Efyriii Watttm Hills 4-1-69 820 8-1-69 277 ————10.0 0 • Euclid 7-1-68 280 Warrensville Hts. 7-1-68 830 l^irview Park 7-1-68 300 Westlake 7-1-68 840 Garfiuid Hts. 7-1-68 320 Wickliffe 7-1-69 860 lltes Mills 7-1-68 330 Willouqhbv 1-1-69 870 Ifphlarid Hts. 7-1-68 370 Willoughby Hills 10-1-68 880 H^ntinq Valley 1-1-69 380 Willowick 7-1-68 890 Independence 1-1-69 390 Woodmere 7-1-68 900 Nprtland 7-1-69 394 1/2% TAX COMMUNITY Lpkewood 7- -68 400 Cuyahoga Hts. 1-1-71' 250 LJnndale 7- r70 420 Middlefield 4-1-69 510 L^nd hurst 7- -68 440 TOTAL - ALL LOCATIONS m ^ MaplE Hts. 7- -68 460 Ipvfield Hts. 7- -68 480 ifpvfield Vil. 7- -68 485 1 have examined this declaration anil1 to the best of my knowledge, Wentn 1- -69 490 it is correct. Ifento' on-the-lake 1- -69 495 &ldlebura Hts. 7- -68 500 Rtorelciad Hills 7-1-68 520 Ijtewburgh Hts. 7-1-68 540 Nfrthfield 10-1-68 545 Denotes current effective date of tax rate AUTHORIZED SIGNATURE DATE J*OR>V CCA-201-4 Revised AUG. 1970 DIVISION OF RECONCILIATION OF MUNICIPAL INCOME TAX TAXATION WITHHELD AND TRANSMITTAL OF WAGE STATEMENTS (W-2) 1971 NAME PLACE OF BUSINESS (CITY: CENTRAL COLLECTION 06^LU QwuucaJL Comamnu — AGENCY TRAOE NAME (IF ANY! ^ *" T f PICA TION NO. ( FORM CC/^102) Type or STREET AbDRESS N y*fK vWB VQCfO-f MS ATTACHED Print Employer' s Name and c1TY ST 15 Address ' ^IT flLa ^K EMPLOYER'S COPY 1 TOTAL OF MUNICIPAL INCOME TAX WITHHELD FROM WAGES (FORMS W - 2)...... -."... ..S 2 TOTAL OF MUNICIPAL INCOME TAX WITHHELD AS REPORTED ON FORM CCA- 102 FOR QUARTER ENDED... A. MAR. 31 S ^29<8. 09 C. SEPT. 30. B. 'JUNE 30...... S __ D. DEC. 31.. 3 TOTAL OF AMOUNTS AS SHOWN ON ^THROUGH 2D ...... """/.* .J...... *-J J} ft /jil (IF DIFFERENT FROM TOTAL LINE 1. ATTACH EXPLANATIONS) » '*T* T I DECLARE THAT I HAVE EXAMINED THIS RETURN, AND TO THE BEST OF MY KNOWLEDGE AND BELIEP IT IS TRUE. SIGNATURE ...... TITL ______^^ FORM CCA-123-l t 4-11— + JN VO fi CJN V£> K> CM -y- CO OJ 'd- CO V£> CV K1) V£> CV P~> n O' to r- in o\ in oo P> (— ve> vc XT in T fo cc- oc vo m c^ to CD 10 vo cotoe t- y\ 0\ O CV 03 o CD cv ex, _, firmrp uto ft ifsryn f$£'o£f rr nod '0 0 V V 01 'Wilt nrpj°¥fy™ °f l&vynr r»^ T*V°± *l 'ltro£~9 4*njpv9 mmyw Wfvont pvz uo vp-aw rwn vow* u EMPLOYER'S QUARTERLY MUNICIPAL TAX RETURN • "•M««.-.•• CENTRAL COLLECTION AGENCY I.*,.* w...... DIVISION OF TAXATION Date Quarter Ended Employer ID No. Date Due 1. Total wages subject to SEPT. 30, 1971 OCT. 31, 1971 withholding ...... $ Name 2. Amount of tax withheld ...... $ 3. Adjustment for preceding quarters of calendar year (PLKAaC tXFLAIN) ...... _.———— f none. 4. Adjusted total of tax withheld .. $ 5. Total of endoMd dapoaitary other ride) ...... $ none. Balance due and paid herewith (Itam 4 minus Item 6) ...... $ ot- BE SURE TO EMCLOSI REMITTANCE AND DEPOSITARY RECEIPTS WITH THIS RETURN MUNICIPALITY * CODE EMPLOYMENT RESIDENCE MUNICIPALITY * CODE EMPLOYMENT RESIDENCE 1% TAX COMMUNITIES North Olmsted 7-1-68 550 Aurora 1-1-69 010 North Randall 7-1-68 560 Bay Village 7-1-68 040 Oakwood 7-1-68 580 Beach wood 7-1-68 050 Olmsted Falls 1-1-69 590 Bedford 7-1-68 060 Orange 7-1-68 600 Bentleyville 1-1-69 090 Pepper Pike 7-1-68 650 Berea 7-1-68 100 Richmond Hts. 7-1-68 670 Bratenahl 7-1-70 120 Seven Hills 7-1-68 720 Brecksville 1-1-69 130 Shaker Hts. 7-1-68 750 Broadview Hts. 1-1-69 140 Sheffield Vil. 7-1-68 752 Brooklyn Hts. 10-1-68 160 South Euclid 7-1-68 770 Chagrin Falls 7-1-68 180 South Russell 1-1-69 772 Chardon 1-1-70 185 Streetsboro 1-1-69 775 Cleveland 7-1-68 200 Strongsville 7-1-68 780 Cleveland Hts. 7-1-68 210 Timberlake ; 10-1-68 788 East Cleveland 7-1-68 270 University Hts. 7-1-68 800 Eastlake 1-1-69 273 Valley View 1-1-69 810 Elyria 8-1-69 277 llO OC Walton Hills 4-1-69 820 ——22^ 4 rY'Yy Euclid 7-1-68 280 Warrensville Hts. 7-1-68 830 Fairview Park 7-1-68 300 Westlake 7-1-68 840 Garfield Hts. 7-1-68 320 Wickliffe 7-1-69 860 Gates Mills 7-1-68 330 Willoughby 1-1-69 870 Highland Hts. 7-1-68 370 Willouahbv Hills 10-1-68 880 Hunting Valley 1-1-69 380 Willowick 7-1-68 890 Independence 1-1-69 390 Woodmere 7-1-68 900 Kirtland 7-1-69 394 1/2% TAX COMMUNITIES Kirtland Hills 4-1-71 395 Cuyahoga Hts. 1-1-71 250 Lakewood 7-1-68 400 Middlefield 4-1-69 510 Linndale 7-1-70 420 NON CENTRAL COLLECTION Lyndhurst 7-1-68 440 TAXING COMMUNITIES Maple Hts. 7-1-68 460 Brooklyn 7-1-68 150 Mayfield Hts. 7-1-68 480 Lorain 10-1-68 435 « ^ * ** i / • / y Mavfield Vill. 7-1-68 485 No. Royalton 7-1-68 570 UK Mentor 1-1-69 490 Parma 7-1-68 620 Mentor-on-the-Lake 1-1-69 495 Parma Hts. 7-1-68 630 ••1 Middleburg Hts. 7-1-68 500 Rocky River 7-1-68 700 Moreland Hills 7-1-68 520 Newburgh Hts. 7-1-68 540 OTHER (ATTACH LIST) 999 SSisSSSMMMHsiS «t r- 1 Northfield 10-1-68 545 TOTAL - ALL LOCATIONS I | /•-?' "Denotes current effective date of Tax Rate. have examined this return and to the best of my knowledge, it is correct. FORM ccA-ioz-3 A j /Ion REVISED AUG. 1971 Date Out. Y), i Requirements for Monthly Deposits - Every employer who is liable for more than $100.00 i"co"|* tax withheld for a onth. is required to deposit such taxes within 20 days after the close of such month to the Division of Taxation? Beposits for the third month of any quarter is not required as the amount due can be filed with the quarterly report. DEPOSITARY RECEIPT RECORD RECEIPT SERIAL NO. DATE OF DEPOSIT AMOUNT This must be used by employers required to make deposits of taxes reportabie on this return. Each deposit should be accompanied by a Receipt Form EM-1 which will be validated by the Division of Taxation and returned to the employer. Validated receipts should be listed here ana must be "enclosed with this return. TOTAL OF ALL ENCLOSED DEPOSITARY RECEIPTS (ENTER IN ITEM SON OTHER SIDE) GENERAL INSTRUCTIONS FOR FORM CCA-102 The instructions below relate to the preparing and filing of Form CCA-102, and is used for the reporting of municipal income tax withheld from wages. Who Must File - If you have one or more employees you must make a return for the first quarter in which you are required to withhold municipal income tax from wages and for each quarter thereafter. If you temporarily discontinue paying wages (for example, seasonal work), you must nevertheless file returns. If you no longer expect to pay wages subject to the tax reportabie on this form you must file a "Final Return". After you have once filed a return, a pre-addressed Form CCA-102 will be mailed to you every three (3) months. If the form should fail to reach you request a Form CCA-102 so that you can file your return on time. Transfer or Sale of Business — If a business is transferred or sold by one employer to another, each employer must file a separate return. Quarterly Returns and Due Dates — A return must be filed for each quarter of the calendar year as follows: QUARTER COVERED QUARTER ENDING DUE ON OR BEFORE January, February, March Marcii 31st April 30th April, May, June June 30th July 31st July, August, September September 30th October 31st October, November, December December 31st Jariuary 31st Where To File - Taxpayers whose business places are located in the communities shown on the front of this return are required to file their return with the Division of Taxation, 1701 Lakeside Avenue, Cleveland, Ohio 44114. Payment of Tax - Each return Form CCA-102 should be accompanied by the remittance (check, money order, depositary receipt or combination of these) for the total taxes reported in Item 6. Employer Identification Number, Name and Address - Pre-addressed Form CCA-102 should be used in filing returns. If pre-addressed form is lost, request another and type or print in the name, address, identification number including all other pertinent information. If you do not have a number, indicate OP the return and a Division of Taxation number will be assigned to you. Penalties and Interest — The law provides penalties for late filing of a return and payments thereof. Avoid penalties and interest by filing returns and payments of tax. Penalties also are imposed by law for willful failure to pay. collect or truthfully account for and pay over tax, keep records, make returns, for false or fraudulent returns, or for submitting bad checks. FORMS W-2 AND CCA-W3 When filing return on CCA-102 for the last quarter of the calendar year or when filing final return if final wages are paid before the end of the year the employer must transmit copies (W-2) of all wages and tax statements issued for the year together with a Form W-3, Reconciliation of Income Tax withheld. Form CCA-W3 will be mailed with return for the fourth quarter. If a final return is filed before the end of the year, Form CCA-W3 should be requested from Division of Taxation. Instructions for Form CCA-W3 are printed on the back of said form. SPECIFIC INSTRUCTIONS Item 1 — Enter only the total taxable wages paid to employees. Do not include wages (paid that are) earned in taxing communities not listed on the front of this return. Item 2 - Enter in Item 2 the amount of income tax withheld on wages. Item 3 — Adjustment of Income Tax Withheld. Item 3 should be used for the correction of errors made in connection with the withholding of income tax from wages paid in the preceding quarters of the same calendar year. Any amount in Item 3 must be explained by a statement enclosed with the return. The statement must set forth: (a) Explanation of the error which is intended to be corrected; (b) The particular return period or periods to which the error relates; c) The amount chargeable to each Such period; and ! d) The manner in which the error has been settled. Item 4 - Adjusted Total Income Tax Withheld. This amount should either be the total or the difference of Items 2 ana 3 depending on whether the items are added or subtracted. Item 6 — The amount indicated in this column must be paid not later than one month following the close of the quarter. li'Ol Ot'l>90Z -yy ill) I 'tl 7 feMPLOYER'S QUARTERLY MUNICIPAL TAX RETURN i«-Fin i R.tum" CENTRAL COLLECTION AGENCY DIVISION OF TAXATION Date Quarter Ended Employer ID No. Date Due i. Total wages subject to ^t 02 f -75 JUNE 30. 1971 ? JULY 31, 1971 withholding ...... t «- , a-- _- Name 7 Amount of tax withheld ...... S ftlQ JC i OttLiLLA ChjAndcaJL (~a ran •> Adjustment for preceding Trade r- ame, If any *- ^ ^r"^ jr quarters of calendar year 5 (PLEASE EXPLAIN) „ „ . __ .. 1 Local Business Address H n&ne at 4. Adjusted total of tax withheld .. i ^^ ?C : i <*"* 1 /"I/ • - 5. Total of enclosed depositary a. Mailing Address a ' ' ' ^ nesdptt (MB nth«r «Me) ...... $ ?//£?. Jfl P 0 Btm 171 City and ZIP Cofle ' ' ^^.> 6. Balance due and paid herewith t~ i (lt«n 4 mini* Item B) $ ,? V^'3? -^ ?^« - —————rTA/f t (Vr— 44044———————————— 1 BE SURE TO ENCLOSE REMITTANCE AND DEPOSITARY RECEIPTS WITH THIS RETURN MUNICIPALITY • CODE EMPLOYMENT RESIDENCE MUNICIPALITY * CODE EMPLOYMENT RESIDENCE 1% TAX COMMU NITIES North Randal! 7-1-68 560 Aurora 1-1-69 010 Oakwood 7-1-68 580 Bay Villaoe 7-1-68 040 Olmsted Falls 1-1-69 590 Beachwood 7 1-68 050 Oranae 7-1-68 600 Bedford 7-1-68 060 Peooer Pike 7-1-68 650 Bentlevville 1-1-69 090 Richmond Hts. 7-1-68 670 Berea 7-1-68 100 Seven Hills 7-1-68 720 Bratenahi 7-1-70 120 Shaker Hts. 7-1-68 750 Brecksville 1-1-63 130 Sheffield Vil. 7-1-68 752 Broaiiview Hts. 1-1-63 140 South Euclid 7-1-68 770 Brooklyn Hts. 10-1-68 160 South Russell 1-1-69 772 Chaqrin Falls 71-68 180 Streetsboro 1-1-69 775 Chardon 1-1-70 185 Stronasville 7-1-68 780 Cleveland 7 -68 200 Timberlake 10-1-68 788 Cleveland Hts. 7- -68 210 University Hts. 7-1-68 800 East Cleveland 7 -68 270 Valley View 1-1-69 810 East lake 1- -69 273 Walton Hills 4-1-69 820 Elvrii 8- -69 277 Warrensville Hts. 7-1-68 830 1&Q.22— ^^It • 29— / Euclid 7 -68 280 Westlake 7-1-68 840 Fairview Park 7- -68 300 Wickliffe 7-1-69 860 Garfield Hts. 7- -68 320 Willouahbv 1-1-69 870 Gates Mills 7- -68 330 Willouahbv Hills 10-1-68 880 Highland Hts. 7- -68 37Q Wiiiowick 7-1-66 aau j Huntinq Valley 1- -69 380 Woodmere 7-1-68 900 Independence 1- -69 39Q 1/2% TAX COMMUNITY Kirtland 7- -69 394 Cuyahoga Hts. 1-1-71 250 Lakewuod 7 -68 400 Middlefield 4-1-69 510 Linndale 7- -70 420 NON CENTRAL COLLECTION Lyndliurst 7- -68 440 TAXING CO \1M UNITIES Maple Hts. 7- -68 46Q Brooklyn 7-1-68 150 Mavfield Hts. 7- -68 480 Lorain 10-1-68 435 rot A. oAo f Mavfield Vil. 7- -68 485 No. Rovalton 7-1-68 570 • Mentor 1- -69 490 Parma 7-1-68 620 Mentor on-the-Lake 1- -69 495 Parma Hts. 7-1-68 630 •• Middlehurq Hts. 7- -68 500 Rocky River 7-1-68 700 Moreland Hills 7- -68 520 Newburqh Hts. 7-1-68 540 IB Northfield 10-1-68 545 OTHER (ATTACH LIST) 999 X m North nimsted 7-1-68 550 ————— TOTAL - ALL LOCATIONS 1 have Kxnmined this return and to th« best of my knowledge, it is correct ronr. REVISE. :^ JAN. 197] Date ~7 Signature Title (Owner, etct>-- _ .. O. vx.cc ^ ry Si'il 99'till *rrr**fyrtf '/V St'LL LL"blll vflnrA-atfp-ry '/y urywy wtoy / -lffl- f' 0 EMPLOYER'S QUARTERLY MUNICIPAL TAX RETURN T,n.iR.w CENTRAL COLLECTION AGENCY Date Quarter Ended I Employer ID Date Due 1. Total wages subject to DEC. 1,1970 j 2/T.0//20, JAN. 31, 1971 withholding ...... $ Name 2. Amount of tax withheld . $ 279.72 3. Adjustment for preceding quarters of calendar year none (PLEASE EXPLAIN) .. ___ 4. Adjusted total of tax withheld . . $ 279. 72 City and ,-,, i, Qfuio 5. Total of enclosed depositary none Mailing A receipts (see other side) ...... $ City and ZIP Code 6. Balance due and paid herewith 279-72 (Item 4 minus Item 5) ...... $ BE SURE TO ENCLOSE REMITTANCE AND DEPOSITARY RECEIPTS WITH THIS RETURN MUNICIPALITY * CODE EMPLOYMENT RESIDENCE MUNICIPALITY * CODE EMPLOYMENT RESIDENCE 1% TAX COMMU NITIES North Randall 7-1-68 560 Aurora 1-1-69 010 Oakwood 7- -68 580 Bay Villaqe 7-1-68 04q Olmsted Falls 1- -69 590 Beachwood 7-1-68 050 pranqe 7- -68 eqg Bedford 7-1-68 060 Peooer Pike 7- -68 650 Bentlevville 1-1-69 090 Richmond Hts. 7- -68 670 Berea 7-1-68 100 Seven Hills 7- -68 720 Bralenahl 7-1-70 120 Shaker Hts. 7- -68 750 Brecksville 1-1-69 130 Sheffield Vil. 7- -68 752 Broadview Hts. 1-1-69 14Q South Euclid 7- -68 770 Brooklyn Hts. 10-1-68 160 South Russell 1- -69 772 Chaqiin Falls 7-1-68 180 Streetsboro 1- -69 775 Chardon 1-1-70 185 Stronasville 7- -68 780 Cleveland 7-1-68 200 Timberlake 10-1-68 788 Cleveland Hts. 71-68 210 University Hts. 7-1-68 800 East Cleveland 7-1-68 270 Valley View 1-1-69 810 Eastlake 1-1-69 273 Walton Hills 4-1-69 820 Elvtia 8-1-69 277 j&.fr~ ^9.92 Warrensville Hts. 7-1-68 830 Euclui 7-1-68 280 Westlake 7- -68 840 Fairview Park 7-1-68 300 Westview 1- -69 850 Garfield Hts. 7-1-68 320 Wickliffe 7- -69 860 Gates Mills 7-1-68 330 Willouqhbv 1- -69 870 Highland Hts. 7-1-68 370 Willouahbv Hills 10- -68 880 Hunting Valley 1-1-69 380 Willowick 7- -68 890 Independence 1-MS9 390 Woodmere 7- -68 900 Kirtland 7-1-69 394 1/2% TAX COMMUNITY Lakewood 7-1-68 400 Middlefield 4-1-69 510 Linndale 7-1-70 420 l/4% TAX COMMUNITY Lyndnurst 7-1-68 440 Cuyahoqa Hts. 1-1-70 250 Maple Hts. 7-1-68 460 NON CENTRAL COLLECTION Mavfield Hts. 7-1-68 480 TAXING COfIMMUNITIES Mavfield Vil. 7-1-68 485 Brooklyn 7-1-68 150 B^l Mentor 1-1-69 490 Lorain 10-1-68 435 fitHwB^^lH /^.// Mentor-on-the-Lake 1-1-69 495 No. Royalton 7-1-68 570 BBHHI Middleburq Hts. 7-1-68 500 Parma 7-1-68 620 i^HRI Moreland Hills 7-1-68 520 Parma Hts. 7-1-68 630 •ES Newburgh Hts. 7-1-68 540 Rocky River 7-1-68 700 Northfield 10-1-68 545 OTHER (ATTACH LIST) 999 aSBBBHB^S il.iy North Olmsted 7-1-68 550 TOTAL - ALL LOCATIONS 209.79\ 69.93 Denotes current effective date of Tax Rate. I have examined this return and tothe best of my knowledge, it is correct FORM CCA-102 REVI-.ED AUG. i 9 io Date /^//Signature .Title (Owner, etc.) . /7 Do you expect to pay Taxable Wages in the future? [_| Yes | ] No If No, write "Final Return" in space provided on the front of this return. Enter date of final payment of taxable wages 19 Requirements for Monthly Deposits — Every employer who is liable for more than $100.00 income tax withheld for a onth. is required to deposit such taxes within 20 days after the close of such month to the Division of Taxation. Beposits for the third month of any quarter is not required as the amount due can be filed with the quarterly report. DEPOSITARY RECEIPT RECORD RECEIPT SERIAL NO. DATE OF DEPOSIT AMOUNT This must be used by employers required to make deposits of taxes reportable on this return. Each deposit should be accompanied by a Receipt Form EM-1 which will be validated by the Division of Taxation and returned to the employer. Validated receipts should be listed here and must be enclosed with this return. TOTAL OF ALL ENCLOSED DEPOSITARY RECEIPTS (ENTER IN ITEM 5 ON OTHER SIDE) GENERAL INSTRUCTIONS FOR FORM CCA-102 The instructions below relate to the preparing and filing of Form CCA-102, and is used for the reporting of municipal income tax withheld from wages. Who Must File — If you have one or more employees you must make a return for the first quarter in which you are required to withhold municipal income tax from wages and for each quarter thereafter. If you temporarily discontinue paying wages (for example, seasonal work), you must nevertheless file returns. If you no longer expect to pay wages subject to the tax reportable on this form you must file a "Final Return". After you have once filed a return, a pre-addressed Form CCA-102 will be mailed to you every three (3) months. If the form should fail to reach you request a Form CCA-102 so that you can file your return on time. Transfer or Sale of Business — If a business is transferred or sold by one employer to another, eoch employer must file a separate return. Quarterly Returns and Due Dates — A return must be filed for each quarter of the calendar year as follows: QUARTER COVERED QUARTER ENDING DUE ON OR BEFORE January, February, March March 31st April 30th April, May, June June 30th July 31st July, August, September September 30th October 31st October, November, December December 31st January 31st Where To File — Taxpayers whose business places ore located in the communities shown on the front of this return 3re required to file their return with the Division of Taxation, 1701 Lakeside Avenue, Cleveland, Ohio 44114. Payment of Tax — Each return Form CCA-102 should be accompanied by the remittance (check, money order, depositary receipt or combination of these) for the total taxes reported in Item 6. Employer Identification Number, Name and Address - Pre-addressed Form CCA-102 should be used in filing returns If pre-addressed form is lost, request another and type or print in the name, address, identification number including all other pertinent information. If you do not have a number, indicate on the return and a Division of Taxation number will be assigned to you. Penalties and interest - The law provides penalties for late filing of a return and payments thereof. Avoid penalties and interest by filing returns and payments of tax. Penalties also are imposed by law for willful failure to pay. collect or truthfully account for and pay over tax, keep records, make returns, for false or fraudulent returns, or for submitting bad checks. FORMS W 2 AND CCA-W3 When filing return on CCA-102 for the last quarter of the calendar year or when filing final return if final wages are paid before the end of the year the employer must transmit copies (W-2) of all wages and tax statements issued for the year together with a Form W-3, Reconciliation of Income Tax withheld. Form CCA-W3 will be mailed with return for the fourth quarter. If a final return is filed before the end of the year, Form CCA-W3 should be requested from Division of Taxation. Instructions for Form CCA-W3 are printed on the back of said form. SPECIFIC INSTRUCTIONS Item 1 - Enter only the total taxable wages paid to employees. Do not include wages (paid that are) earned in taxing communities not listed on the front of this return. Item 2 — Enter in Item 2 the amount of income tax withheld on wages. Item 3 - Adjustment of Income Tax Withheld. Item 3 should be used for the correction of errors made in connection with the withholding of income tax from woges paid in the preceding quarters of the same calendar year. Any amount in Item 3 must be explained by a statement enclosed with the return. The statement must set forth: (a) Explanation of the error which is intended to be corrected; (b) The particular return period or periods to which the error relates; (c) The amount chargeable to each such period; and (d) The manner in which the error has been settled. Item 4 - Adjusted Total Income Tax Withheld. This amount should either be the total or the difference of Items 2 ana 3 depending on whether the items are added or subtracted. Item 6 — The amount indicated in this column must be paid not later than one month following the close of the quarter. cal Company $4-0420884 " P. 0. Box 375 fltAJUOL, 0/Uo DonoM fauthuv N. f^d^vjuULe. 1116.^ 77.77 77.77 DIVISION OF RECONCILIATION OF MUNICIPAL INCOME TAX 1Q"7fi TAXATION WITHHELD AND TRANSMITTAL OF WAGE STATEMENTS (W-2) 1 +9 i \J NAME PLACE OF BUSINESS (CITY CENTRAL COLLECTION OoJUUL& C;ie.mJLc.oJL (^ompanu AGENCY TRADE NAME (IF ANY) ' •* EMPLOYER'S IDENTIFICATION NO. ( FORM CCA- 102) Type tl-( Ulfifind. or STREET ADDRESS f E"R OF 'W - 2 FOR faS ATTACHED Print Employer's 1 $2. Locu^J \Jn.0.&J Nome CITY. STATE AND ZIP CODE 29 and Address FJjinJiA, Ohio UtiOW EMPLOYER'S COPY 1 TOTAL OF MUNICIPAL INCOME TAX WITHHELD FROM WAGES (FORMS W-2!...... 7/03.3^- 2 TOTAL OF MUNICIPAL INCOME TAX WITHHELD AS REPORTED ON FORM CCA- !02 FOR QUARTER ENDED.. A. MAR. 31 ...... «i 27y.^>7______C' SEPT. 30...... S ._ B. JUNE 30...... S._2fi2j./Z—— ------___ D' DEC- 31...... ,...S_ 3 TOTAL OF AMOUNTS AS SHOWN ON LINES 2A THROUGH 2O...... ______(IF DIFFERENT FROM TOTAL LINE I. ATTACH EXPLANATIONS) I DECLARE THAT I HAVE EXAMINED THIS RETURN^A/ND TO THE BEST OF MY KNOWLEDGE AND BELIEF IT IS TRUE, t / > // / , / A // / j^S DATE . MMJ. .?/...... FORM CCV-120-1 CCA-W3 c : A - w INSTRUCTIONS FOR FORM CCA-W 3 T. WHO MUST FILE - Each employer must file Form CCA-V 3 wirch serves as the transrnitta I statement for Form W-2 for rrr Any difference between rhe amount on line 1 and the amount on line 3 must be fully explained in an attached statement 4. MAILING — Large numbers of Form W 2 may be forwarded in consecutively numbered packages of convenient si;e, identified by the employer's name, federal identification number, and tne number of packcg.es that will be ser 1. if more than one package of V' 2's are t > be sent, they shall be grouped into cities of residence of the employees in order not to delay the auditing of the yeoi end report. All forms and packages sent by mail are recuired -o be sent First Class Mail and mailed t> 1701 LAKESIDE AVFNUF, CLEVELAND, OHIO 44114. 5. PLACE OF BUSINESS - List on the front of tiis return the City where the place of business is located. If business is conducted in more than one place, 'hen attach a statement and indicate thereon *he cities where the business s located. i ^ N > ^ \ N EMPLOYER'S QUARTERLY MUNICIPAL TAX RETURN CENTRAL COLLECTION AGENCY ...... DIVISION OF TAXATION Date Quart* Endwl Employer ID No. Date Due 1. Total wagts subject to MAR. 31,1971 1U.-OU2088U. APR. 30,1971 withholding...... i 29.801. 2. Amount of tax withheld ...... $ . OQ 3. Adjustment for preceding quarters of calendar year (PLIA8E IXPLAIN) ...... ____ $ 4. Adjusted total of tax withheld .. $ 298.09 5. Total of enclosed depositary Mailing (see other side) ...... $ none. City and ZIP Cod* * 6. Mann due and paid herewith OLio (Item 4 minus Item 6) ...... $ 298.09 BE SURE TO ENCLOSE REMITTANCE AND DEPOSITARY RECEIPTS WITH THIS RETURN MUNICIPALITY • CODE EMPLOYMENT RESIDENCE MUNICIPALITY • CODE EMPLOYMENT RESIDENCE IK TAX COMMU NITIES North Randall 7-1-68 560 Aurora 1-1-69 010 Oakwood 7-1-68 580 Bav Villaoe 7-1-68 Q4Q Olmsted Falls 1-1-69 590 Beachwood 7-1-68 050 Oranae 7-1-68 600 Bedford 7-1-68 060 Peooer Pike 7-1-68 650 Bentlevville 1-1-69 090 Richmond Hts. 7-1-68 670 Berea 7-1-68 100 Seven Hills 7-1-68 720 Bratenahl 7-1-70 120 Shaker Hts. 7-1-68 750 Brecksville 1-1-69 130 Sheffield Vil. 7-1-68 752 Broadview Hts 1-1-69 140 South Euclid 7-1-68 770 Brooklyn Hts. 1D-1-B8 160 South Russell 1-1-69 772 Chaarin Falls 7-1-68 180 Streetsboro 1-1-69 775 Chardon 1-1-70 185 Stronasville 7-1-68 780 Cleveland 7-1-68 200 Timberlake 10-1-68 788 Cleveland Hts. 7-1-68 210 ' University Hts. 7-1-68 800 East Cleveland 7-1-68 270 Valley View 1-1-69 810 Eastlake 1-1-69 273 Walton Hills 4-1-69 820 Elvria 8-1-69 277 m.. $7 fa.R-> Warrensville Hts. 7-1-68 830 t Euclid 7-1-68 280 ' Westlake 7-1-68 840 Fairview Park 7-1-68 300 Wrckliffe 7-1-69 860 Garfield Hts. 7-1-68 320 Willouahbv 1-169 ?70 ,'-'i Gates Mills 7-1-68 330 Willouohbv Hills 10-1-68 880 Hiohland Hts. 7-1-68 370 Willowick 7-1-68 890 Hunting Vallev 1-1-69 380 ————— Woodmere 7-1-68 900 Indeoendence 1-1-89 390 1/2% TAX COMMUNITY Kirtland 7-1-69 394 Cuyahoga fits. 1-1-71 250 Lakewood 7-1-68 400 Middlefietd 4-1-69 510 Linndale 7-1-70 420 NON CENTRAL COLLEtITION Lvndhurst 7-1-68 440 TAXING CO I/IMUNIT CO Maole Hts. 7-1-68 460 Brooklyn 7-1-68 150 Mavfield Hts. 7-1-68 480 Lorain 10-1-68 435 Mavfield Vil. 7-1-68 -181L No, Rovalton 7-1-68 570 Mentor 1-1-69 490 Parma 7-1-68 620 Mentor-on-the-Lake 1-1-69 495 Parma Hts. 7-1-68 630 Middleburg Hts. 7-1-68 500 Rocky River 7-1-68 700 Moreland Hills 7-1-68 520 OTHER (ATTACH LIST) 999 = •li. W Newburqh Hts. 7-1-68 540 TOTAL - ALL LOCATIONS 772 C7 7,1 ^2 Northfield 10-1-68 545 ' i North Olmsted 7-1-68 550 ——— | " Denotes currant effective date of Tax Rat*. I have examined thfe return end to the belt of my knowledge, it it correct FORM CCA-102 REVISED JAN. 1971 Date 4-J6-71 . Signature . Title. (Owner, etc.) VJJC-&- -I 50, /?7/ D N. 1J20.18 $11.20 HARRY J. P. WOLTZ, CERTIFIED PUBLIC ACCOUNTANT, ELYRIA, OH IO INSTRUCTIONS FOR FIL'ING ATTACHED RETURN j fifi AA Make check for $______// *-* I / _ In payment of: Payable to: ___ F. I .C.A. & Withholding Tax ___Internal Revenue Service Federal Income Tax ___Treasurer, ______County _Federal Estimated Income Tax____ Bureau Of Employment Services _State UnempIoyment Tax Treasurer, State Of Ohio _Federal Unemployment Tax Central Collection Agency JDeposit For Withheld Taxes Other _Workmen's Compensation Insurance _Sa I es Tax _ , . ... _PersonaI Property-Bus i ness-Persona I Refund Due Of $ Franchise Tax & Security Valuation MaiI to: l-y I ncome Tax / *7 ~?& ___Internal Revenue Service City Estimated Income Tax Cincinnati, Ohio 45298 Other ~ ___Enclosed envelope ___Auditor, ______County Be sure report is dated and signed by: Central Collection Agency Deposit orlfei I before -3 0 7/ 1701 Lakeside, Cleveland, Ohio 44114 s Other _P°Py enclosed for your records IMPORTANT: To avoid penalty charges sign and mai I report on or before due date even though you do not send the money. NET PROFITS TAX RETURN ' ANNUAL FROM BUSINESS, PROFUSION OR OTHER ACTIVITY BY INDIVIDUALS, PARTNERSHIPS, ESTATES OR TRUSTS, RETURN CORPORATION FOR CALENDAR YEAR 1970 t FORM OR FISCAL YEAR BEGINNING . .1970 AND ENDING. 1971 1970 CCA 120-17 (THIS RETURN MUST BE FILED EVEN THOUGH FINAL COMPUTATION RESULTS IN NET LOSS) FEDERAL IDENT. NO. . NAME ...... Dt.|.t.ts..Ch»m|.c»I-Cowpany- SOCIAL SECURITY NO. TRADE NAME...... MAILING ADDRESS ...... If individual owner, horn* oddross LOCAL BUSINESS ADDRESS...W2..|, CITY AND 2IPCODE...... £tVCl*>...QhI.0..4AQ35...... NATURE OF BUSINESS (COMPLETE APPROPRIATE SCHEDULE AND ENTER ONLY ACTUAL TAX OFFICE USE FIGURES HERE) ONLY PROCESSED BY TAXABLE PROFITS FROM: 1. TAXABLE WAGES FROM (SCHEDULE G)_ $ 2. PARTNERSHIPS AND ASSOCIATIONS (SCHEDULE A) $ DATE OF AUDIT 3. RENTS (SCHEDULE B) $ APPROVED BY 4. BUSINESS OR PROFESSION (SCHEDULE C) _ _ $ I2?l7r?7 5. INCOME FROM ALL OTHER SOURCES (SCHEDULE E) $ REFUND APPROVED 6. TOTAL TAXABLE INCOME $ 12217,27 r TAX DUE AND CREDITS 7. TAX DUE SEE (INSTRUCTIONS) $ I55M7 REFUND CHECK NO. (A) CREDIT ALLOWABLE FROM PREVIOUS YEAR $ f 8. CREDITS: (B) PAYMENTS ON 1970 ESTIMATED TAX $ IO.JOO (C) IF AMENDED RETURN, TAX PAID ON PRIOR RETURN $ i (D) TAX WITHHELD FROM (SCHEDULE G) $ : (E) TOTAL CREDITS ALLOWABLE * IOJ.OO 9. TOTAL DUE AND PAID WITH THIS RETURN (LINE 7 LESS LINE 8 10. OVERPAYMENT CLAIMED (IF LINE 8 '(E) EXCEEDS LINE 7, ENTER DIFFERENCE HERE ______IP BUSINESS TERMINATED COMPLETE THIS BLOCK______ 11. ENTER AMOUNT OF LINE 10 YOU WANT CREDITED TO IF YOU TERMINATED YOUR BUSINESS 1971 TAX ?_....._...___.__....___REFUNDED. $._ GIVE EXACT DATE ______ 4. Were any of your prior years' Federal Income Tax Returns IF YOU SOLD YOUR BUSINESS (OR ASSETS QUESTIONS examined and/or changed during 1970? QNct Examined UPON LIQUIDATION) WRITE PURCHASER'S (Answer fully-usa extra shaat If nacessory) QChanged * QExomlned but Unchanged NAME ______1. Picas* cheek all applicable block.) You ara required to Inform this office within 30 days of O Individual Ownar any change in your U.S. Tax Return affecting profits, O Resident ADDRESS ______D Partnorship- earnings or expenses. QNon-Reildent jQrCorporation 5. Did you hove any employees betwaen January 1,1970and IF BUSINESS ENTITY CHANGED DURING Y 2. Data business startad UEstote or Trust December 31, 1970 Q " D No PAST YEAR, MARK APPROPRIATE 6. On which basis are your records leapt? QCash Q Accrual or trust created) ______BLOCKS. 3. If you filed a Return for a prior year, Q Cash and Accrual Combination Q Completed Contract what was the latest year? ______[pother (explain) ______FROMiQlndlvldual ^Partnership QCorp. I HEREBY CERTIFY UNDER THE PENALTIES PROVIDED BY LAW THAT ALL STATEMENTS MADE HEREIN AND/OR IN ANY SUPPORTING SCHEDULE ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I IF NOT TAXPA YE R DATE AXF THIS RETURN MUST BE FILED AND TAX PAID IN FULL ON 01 , 19?LtOR WITHIN 120 DAYS FROM CLOSE OF YOUR FISCAL, IF FISCAL YEAR IS Dl ROM THE CALENDAR YEAR) MAKE CHECK OR MONEY ORDER PAYABLE TOt CENTRAL COLLECTION AGENCY. MAIL TO DIVISION OF TAXATION, 1701 LAKESIDE AVENUE, CLEVELAND, OHIO 44114. COPY OF FEDERAL RETURN CAN BE ATTACHED IN LIEU OF COMPLETING SCHEDULE C Page 2 A SEPARATE SCHEDULE WIST BE COMPLETED FOR EACH BUSINESS SCHEDULE C TAXABLE PROFIT (OR LOSS) FROM BUSINESS OR PROFESSION EMPLOYER'S IDENTIFICATION NUMBER._. LINE 1. TOTAL RECEIPTS $_____...____LESS ALLOWANCES, REBATES AND RETURNS __. $_ 2. INVENTORY BEGINNING OF YEAR ______$._ 3. MERCHANDISE PURCHASED $______LESS ANY ITEMS WITHDRAWN FROM BUSINESS FOR PERSONAL USE $——————————————————_- 4. COST OF LABOR (DO NOT INCLUDE SALARY PAID YOURSELF). 5. MATERIAL AND SUPPLIES______. 6. OTHER COSTS (EXPLAIN IN SCHEDULE C-2)______. 7. TOTAL OF LINES 2 THROUGH 6 ______.______$._ 8. INVENTORY AT END OF YEAR ______9. COST OF GOODS SOLD (LINE 7 LESS LINE 8) ______L£_ 10. GROSS PROFIT (LINE 1 LESS LINE 9) ______I .. OTHER BUSINESS DEDUCTIONS 11. SALARIES AND WAGES NOT INCLUDED ON LINE 4 (DO NOT INCLUDE ANY PAID TO YOURSELF) $._ .**• 12. RENT ON BUSINESS PROPEHTY.(STATE BELOWTO WHOM PAID)______. 13. INTEREST ON BUSINESS INDEBTEDNESS ______14. TAXES ON BUSINESS AND BUSINESS PROPERTY______15. LOSSES OF BUSINESS PROPERTY (EXPLAIN IN SCHEDULE C-2) ______16. BAD DEBTS ARISING FROM SALES OR SERVICES (EXPLAIN IN SCHEDULE C-2). 17. DEPRECIATION AND OBSOLESCENCE (EXPLAIN IN SCHEDULE C-1) ______. 18 REPAIRS ______19. OTHER BUSINESS EXPENSES (EXPLAIN IN SCHEDULE C-2) ______20. TOTAL OF LINE 11 THROUGH 19 ______J_ 21. TAXABLE PROFIT (OR LOSS) FROM BUSINESS OR PROFESSION (LINE 10 LESS LINE 20) ENTER HERE (IF NET PROFIT INCLUDES NON TAXABLE INCOME COMPLETE SCH. X)______$______12095 10 22. ADJUSTMENT TO TAXABLE INCOME (FROM SCH. X LINE 14-PAGE 3)______._. jL______>22 17 23. ADJUSTED TAXABLE INCOME (LINE 21 PLUS OR MINUS LINE 22 ) ______* 12217 27 24. A. AMOUNT ALLOCABLE:______% OF LINE 23, SCHEDULE C ONLY - FORM CCA 120-19 AND ATTACHED HERETO______.______._ _.. $ 25. LESS ALLOWABLE NET LOSS PER PRIOR YEARS NET PROFIT RETURN (CCA 120-17) ATTACH SCHEDULE__...__.______.._____..__...______.___... -*- 26. ADJUSTED TAXABLE INCOME (LINE 21 OR LINE 24MINUS LINE 25 ENTER HERE AND ONLINE 4, PAGE 1_.__.______.___..__...._.__.....__.__.__....—.___-—————-----————— -$_ ***NAME ______ADDRESS ______(PROPERTY OWNER'S NAME)______STREET______CITY______SCHEDULE C-1 EXPLANATION OF DEDUCTIONS FOR DEPRECIATION AND OBSOLESCENCE CLAIMED IN SCHEDULE C 1. Kind Of Property (If Building State Ma-jerial Of 2. 3. _ , _, 4. Depreciation 5. Method Of 6. Rate (%) 7. ,-..„„.,,„ Which Constructed.) Exclude Land And Other A°",!.d othaVaJ-ls Allowed (or Allow- Computing Or For Th* YeTr Nondepreciable Property. Acquired Other Basis able) in Prior Years Depreciation Life (Years) For This Year $______..___ SCHEDULE C-2 EXPLANATION OF OTHER DEDUCTIONS CLAIMED IN SCHEDULE C Line No. Explanation Amount Line No. Explanation Amount Page 3 SCHEDULE X- RECONCILIATION WITH FEDERAL INCOME TAX RETURN IF USED - FEDERAL RETURN MUST BE ATTACHED -NOT TO BE COMPLETED BY SELF EMPLOYED ITEMS NOT DEDUCTIBLE ADD ITEMS NOT TAXABLE DEDUCT 1. CAPITAL LOSSES (FROM FED SCH. D)______$_____ 8. CAPITAL.GAINS PER FED SCH. D______.______$_____ 2. EXPENSES INCURRED IN THE PRODUCTIONS 9. INTEREST EARNED OR ACCRUED__.______$_____ OF NON-TAXABLE INCOME (ABSENCE OF AC- 10. DIVIDENDS (LESS FED. EXCLUSION)______$_____ TUAL RECORDS-EXPENSES LIMITED TO 5% OF NON-TAXABLE INCOME)______$_____ 11. INCOME FROM PATENTS AND COPY RIGHTS_____ $_____ 3. ALL INCOME TAXES PAID OR ACCRUED______$ 122. 17 12. OTHER (EXPLAIN)______$ 4. PAYMENTS TO PARTNERS______$______5. NET OPERATING LOSS (PER FED RETURN)______$_ 13. A. TOTAL OF LINES 8 THRU 12————————————— $ 6. OTHER: (EXPLAIN)______$ B. AMOUNT FROM LINE 7_ 14. DIFFERENCE BETWEEN LINE 13 A AND 13 B 7. TOTAL OF LINES 1 THRU 6————————————————— $ 179, J7 ENTERED HERE AND ON PAGE 2, LINE 22)_____ $ i??- INCOME FROM PARTNERSHIPS AND ASSOCIATIONS (PARTNERSHIPS & ASSOCIATIONS) SCHEDULE A LOCATED IN CENTRAL COLLECTION COMMUNITIES, MUST FILE AS ONE ENTITY. Column 1 Column 2 . , . Your share of Amount on which Name, Address and Fed. Ident. No. of Partnership, Associations, etc. Partnership etc. City Tax Profits was paid LINE 27. TOTAL ON WHICH CITY TAX IS DUE(COLUMN 1 LESS COLUMN 2) (ENTER HERE AND ON PAGE 1, LINE 21.______..__ . ______,_____..——______. ._____$_. ——— — INCOME FROM RENTS - IF MORE THAN ONE PROPERTY INVOLVED - GIVE COMPLETE BREAKDOWN SCHEDULE B AND ADDRESS OF EACH - JOINTLY OWNED PROPERTY MUST FILE AS ONE ENTITY. 1. 2. Amount 3.Depreciation or I 4. Repairs | 5. Other Expenses Location of property of Rent •tn.iJrttiruii'osxi.re.rri 'rexj.ia'in'm (Itemize in in Schedule B-l Schedule B-?) Schedule B-Z) LINE28..A. NET PROFIT (COLUMN 2 LESS SUM OF COLS. 3, 4, & 5)....——————..——————..._...———.___.______. ____ B. RENTAL LOSS PRIOR YEARS BALANCE 1967 ______$______. 1968 ______$______1969 ______$-.-______TOTAL t__ (IF PROPERTIES ARE LOCATED IN MORE THAN ONE COMMUNITY—SHOW BREAKDOWN BY COMMUNITY) C. NET PROFIT FROM RENTS AFTER LOSS ADJUSTMENT (ENTER HERE AND ON PAGE 1, LINE 3)————_ —— SCHEDULE B-1 EXPLANATION OF DEDUCTIONS FOR DEPRECIATION OR DEPLETION CLAIMED IN SCHEDULE B 1. Kind of property {if buildings, state material 2. 3. 4. Depreciation 5 Method of g. Rate (%) 7 of which constructed).Exclude land and Date Cost or allowed (or computing or life Depreciation other depreciable property. acquired other basis allowable) in depreciation (years) for this year prior years SCHEDULE B-2 EXPLANATION OF DEDUCTIONS FOR REPAIRS AND OTHER EXPENSES CLAIMED IN SCHEDULE B Number EXPLANATION AMOUNT Number EXPLANATION AMOUNT SCHEDULE E TAXABLE INCOME FROM ALL OTHER SOURCES (Attach Explanation) LINE 29. A ESTATES AND TRUSTS———_____ .$_ B. PREVIOUS BAD DEBTS COLLECTED C. OTHER ______D. TOTAL TAXABLE INCOME (ENTER HERE AND ON PAGE 1, LINE 5) SCHEDULE G INCOME FROM WAGES, SALARIES, COMMISSIONS AND DIRECTORS FEES A. Name of Employer— Address B. City Where Earned C. Income D. Tax Withheld LINE 30. TOTAL TAX WITHHELD COLUMN D-W2 OR FORM 1099 MUST BE ATTACHED FOR EACH EMPLOYER LISTED (FNTFRWFRF AIMnnN PARE 1, I INERDl « LINE 31. A. TOTAL INCOME (COLUMN C) 1 B. LESS DEDUCTIBLE EXPENSES ALLOWA BLE (ATTACH FORM CCA 120-15 OR FE;DERAL2106U $. C. TAXABLE INCOME (LINE 31A LESS 31B I ENTER HERE AND ON PAGE 1, LI MF 1 « SCHEDULE H DISTRIBUTION OF PROFITS FROM PARTNERSHIPS, ASSOCIATIONS, ETC. (If more space is required, attach schedule) DISTRIBUTIVE NAMES OF PARTNERS OR MEMBERS SOCIAL SECURITY NO. ADDRESSES SHARES OF PROFITS TOTAL (To agree with Line 21 or Line 23, Schedule C, Page 2, if this return i $ r U.S. Corporation Income Tax Return Ferm 1120 For calendar yMr 1*70 or other UMibt* y*ar beginning * MM Tfwwnr ItTO. ending 1*. «M« MNM (PUCABE TYPE OK PMINT) Ctock If •— * WK 34-04?0«84 FOR DEC 31 1971 0034 A CwwHMM ntw» D __ OPITT5 CHEMICAL CO 34-0420884 MM 14? LOCUST ST PO BOx 375 • CM** ta Mick OH 44035 • Nnotul HaHIm Co. D LoraIn C Swims Codi No. (S« pit* F Enter Mil MM(I fnm llm ToriMtnctiMi.) 14,*aliiiwi (D), »rt 2898 L (JW lirftrartU R) IMPORTANT—Fill In ill applicable lines ind schedules. If ttii llnti on tht schedules ire not sufficient, M« hntructlon N. | 90455.36 1 Gross receipt! or grow sales ...... IMS: Returns ind iltowinces , 266155.64 2 Less: Cost of goods sold (Schedule A) and/or operations (attach schedule) . 200854.02 3 Gross profit ...... 4 Dividends (Schedule C) ...... I ...... 5 Interest on obligations of the United States and U.S. instrumentalities . . I Other interest ...... 7 Gross rents . .... ^ ...... 8 Gross royalties ...... 9 Net gains (losses)—(separate Schedule D) ...... id Other income (attach schedule) ...... II____TOTAL InconW—Add lines 3 through 10 ...... 12 Compensation of officers (Schedule E) . . . 13 Salaries and wages (not deducted elsewhere) . 14 Repairs (do not include capital expenditures) . 15 Bad debts (Schedule F If reserve method is used), 16 Rents ...... 5.6.3.2,.J6...... 17 Taxes (attach schedule) 18 Interest ..... IIIiJfcLsIII 19 Co^btfions(ixjtover5 perln*tn^^ 20 Amortization (attach schedule) ...... 21 Depreciation (Schedule G) ...... 22 Depletion ...... 23 Advertising ...... 24 Profit sharing, stock bonus, pension and annuity plans (see instructions) 25 Other employee benefit plans (see instructions) ...... 26 Other deductions (attaflft schedule) ...... 27 TOTAL deductions on lines 12 through 26...... 33186.52 28 Taxable income before net operating loss deduction and special deductions (Hne 11 less line 27) 12095.10 29 Lees: (a) Net operating toss deduction (see instructions-— attach schedule) (b) Special deductions (Schedule I). 30 Taxable income (line 28 less line 29) ...... f . t . . •. ;. .,„ 31 TOT»*TAX (Schejdule J) ...... 32 Credits; (a) T« peM (ileenii»eiO *tth Fena 7004 appUcrtoa for erteteien (stteca seay). (b) Estimatedtcth-OversayiMatfrom 10eYeflowee1 asaaradlt. 1970 estimated tax payments (depostts) ...... Less refund of 1970 estimated tax applied ft in Form 446k. I (c) Cradtt from r*uMed Hivestmtnt eempanies (ittscb Form 2489) (d) JiLS. tax on special fuels, nonWghway gas and lubrfcatke oil (attach Form 4136) . 3S TAX DUE (line 31 less Itne 32). See instruction Q for depositary method of payment 14 OVERPAYMENT (line 32 tass Itne1 31) ...... xl m*" * p*K», I MUM «MI k*M«H«N4 MtMtUII nt tMtUfaT If pnvmil I* • pp*n*e Mtar Ikwi HM t«iM*r MAWY I. r». W©tT2 •lYUtlSAVlNdf CLYIUA, OHIO