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General - Hotel and Motel Tax Form

2. Date Range
   Date Range Start Date

   —

   Date Range End Date

4. Name*

6. Address*

10. 1. Group receipts*

    (All hotel and motel lodging furnished guests)

12. 2. Exempt receipts*

    (Permanent guest, continuous lodging over 30 days)

14. 3. Other exemptions*

    (Attach exemption certificate) tax

16. 4. Total exempt Receipts*

    (Add lines 2 and 3)

18. 5. Net taxable receipts*

    (Line 1 less line 4)

20. 6. Tax due*

    (Enter 3% of line 5)

22. 7. Adjustments - prior period*

    (Include an explanation)

24. 8. Penalty *

    (10th per month for late payment)

26. 9. Total tax due *

    (Sum of lines 6, 7 & 8)

28. Attachments

    (Please upload any necessary or required attachments)

32. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. I hereby certify that the information and statements contained herein and in schedule of exhibition attached are true and correct)

    1. I agree.
34. Electronic Signature*

36. Title*

40. Please note:
    To avoid penalty and interest, payments must be received on or before the 15th of the month following the taxing period.

    To avoid penalty and interest, payments must be received on or before the 15th of the month following the taxing period.

42. Ownership / Name Change
    Notify the Treasurer or any change in ownership or name change.

    Notify the Treasurer or any change in ownership or name change.

Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field