County Name ___________________________
County Innkeepers Tax Return
To be led with County Treasurer’s Oce
□ Amended Return
Federal Tax ID State Tax ID Period End Date Due on or before the 20th day
following the month collected.
Entity Name County Code
Street City State ZIP Code
Location Name Enter Address if Dierent From Above
Authorized Signature
_______________________________
I declare under penalties of perjury
that this is a true, correct and complete
return.
Date: ______________
Phone Number: __________________
Printed Name of Person Signing This
Return
_______________________________
Title: ___________________________
Total Receipts from Rental of Accommodations
......................... A. ________________
Total Exempt Rentals of Accommodations ................................. B. ________________
Net Taxable Receipts (Subtract Line B from Line A) .................. C. ________________
County Innkeepers Tax Due (Line C X Rate) ............................. D. ________________
Collection Allowance ________
Do Not Use this Line if the Payment is Late ............................... E. ________________
Net Tax Due (Subtract Line E from Line D) ................................ F. ________________
Penalty is Greater of $5 or 10% of Line D (Plus Interest)
Use this line only if return is led late ......................................... G. ________________
Adjustments − If this is a negative entry, use a negative sign.
(you must attach an explanation) ............................................... H. ________________
Amount Due (Total Lines F and G plus or minus H) ................... I. ________________
For annual interest rates
see Department of Revenue Departmental Notice #3.
The permissible collection allowance rate is based on your annual tax liability for all
locations in county last year.
• If your annual liability did not exceed $60,000 the permissible rate is 0.73%.
• If your annual liability was greater than $60,000 but did not exceed $600,000
the permissible rate is 0.53%.
• If your annual liability was greater than $600,000 the permissible rate is 0.26%.
Important: This form must be led even though no tax is due.
Please le and remit payment to:
For Ocial Use Only
(Revised 5-18)
