PAGE 1
REVISED 12/1/2017
CITY OF LA GRANDE / UNION COUNTY
TRANSIENT ROOM TAX RETURN
OWNER__________________________________ BUSINESS NAME______________________________
BUSINESS ADDRESS___________________________________________PHONE____________________
NUMBER OF ROOMS__________ MONTH / YEAR COVERED____________________
1. Gross Rents-------------------------------------------------------------------------------------------$____________
2. Rent by the month----------------------------------------------------$____________
3. Rent less than $2 per day-------------------------------------------
$____________
4. Gross receipts from Transient Lodging Intermediaries ------$____________
(Use work sheet on page 2)
5. Total allowable deductions, total Lines 2 through 4 --------$____________
6. Taxable rents (subtract line 5 from line 1)----------------------------------------------------$____________
7. Tax @ 6% of line 6 (City of La Grande)---------------------------$____________
8. Tax @ 3% of line 6 (Union County)-------------------------------
-$____________
9. Add excess tax collected --------------------------------------------$____________
10. TOTAL TAX COLLECTED: (total lines 7, 8 & 9)------------------
$____________
11. Operator’s Collection Fee (5% of line 7)-------------------------$____________
12. Operator’s Collection Fee (5% of line 8)-------------------------$____________
13. TOTAL TAX DUE (subtract lines 11 & 12 from line 10)------------------------------------ $____________
14. PENALTY: (10% if fail to remit any tax imposed by Ordinance prior to delinquency.
A second delinquent penalty of 15% if 30 days past first delinquency.)
$____________
15. INTEREST: (.5% per month of the amount of tax due, excluding penalties, from the
Date on which the remittance first became delinquent until paid.)----- $____________
16. Adjustments for prior shortage or (overpayments)----------------------------------------
17. TOTAL TAX, PENALTY AND INTEREST: (line 13 through 15 or subtract line
16 if overpayment)---------------------------------------------------------------------------------$____________
I DECLARE, UNDER PENALTY OF MAKING A FALSE STATEMENT, THAT TO THE BEST OF MY
KNOWLWEDGE AND BELIEF, THE STATEMENTS HEREIN ARE CORRECT AND TRUE.
SIGNED____________________________________________DATE___________________________
SEND PAYMENT TO: CITY OF LA GRANDE PO BOX 670 LA GRANDE, OR 97850
Please call our office @ (541) 962-1313 if you have questions calculating interest or penalties
PAYMENTS ARE DUE BY THE 15
TH
OF THE MONTH FOLLOWING COLLECTION MONTH
DATE FILED _________________ CHECKED AND RECIEPTED BY_______________
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
PAGE 2
REVISED 12/01/2017
CITY OF LA GRANDE / UNION COUNTY
TRANSIENT ROOM TAX RETURN
Transient Lodging Intermediaries Worksheet
Identify all gross receipts from transient lodging intermediaries for the month. A transient
intermediary is a person, other than a provider, who facilitates the retail sale and charges for all
the occupancy of transient lodging. Transient lodging intermediaries include, but are not limited
to online travel companies, travel agents, and tour outfitter companies.
Gross Receipt Amount
Month Ending__________
Company Name or Transient Lodging Intermediary
Address
Company Name or Transient Lodging Intermediary
Address
Company Name or Transient Lodging Intermediary
Address
Company Name or Transient Lodging Intermediary
Address
Company Name or Transient Lodging Intermediary
Address
Company Name or Transient Lodging Intermediary
Address
Company Name or Transient Lodging Intermediary
Address
Company Name or Transient Lodging Intermediary
Address
Company Name or Transient Lodging Intermediary
Address
Grand Total Transfer to Page 1, line 4
$ 0.00