STATE OF CALIFORNIA
HOTEL/MOTEL TRANSIENT OCCUPANCY TAX WAIVE
EXEMPTION CERTIFICATE FOR STATE AGENCIES
TD.236 (NEW 9-91)
HOTEL/MOTEL OPERATOR: RETAIN THIS WAIVER FOR YOUR FILES TO SUBORDINATE YOUR REPORTS. DATE
PARTICIPATION BY OPERATIONS IS STRICTLY VOLUNTARY
HOTEL/MOTEL NAME
TO:
HOTEL/MOTEL ADDRESS (Number, Street, City, State, ZIP Code)
This is to certify that I, the undersigned traveler, am a representative or employee of the State agency
indicated below; that the charges for the occupancy at the above establishment on the dates set forth
below have been, or will be paid for by the State of California; and that such charges are incurred in
the performance of my official duties as a representative or employee of the State of California.
OCCUPANCY DATE(S) AMOUNT PAID
STATE AGENCY NAME
HEADQUARTERS ADDRESS
TRAVELER'S NAME (Printed or Typed)
I hereby declare under the penalty of perjury that the foregoing statements are true and correct.
EXECUTED AT: (City) TRAVELER'S SIGNATURE DATE SIGNED
, CALIFORNIA
92 64268
