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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.
42. Ownership / Name Change
    Notify the Treasurer or any change in ownership or name change.
Leave This Blank:


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

    This field is not part of the form submission.

46. Submit

* indicates a required field