TOWN OF CULPEPER
400 South Main Street, Ste. 109
540-829-8240
Due on or before the 20
th
of each month following month for which report is made.
Business Name: Federal ID No.:
Owner Name: Customer No.:
MONTHLY REMITTANCE OF LODGING TAX
1. Gross receipts for the month of ___________________, 20________ $
2. LESS allowable deductions
(must attach list) . . . . . . . . . . . . . . . $ __________________
3. Balance taxable . . . .
(line 1 – line 2). . . . . . . . . . . . . . . . $
4.
6% tax on item 3 . . . (.06 x line 3) . . . . . . . . . . . . . . . . . $
5. LESS 3% sellers discount on item 4
(.03 x line 3 if paid by 20
th
of month). . . . $
6. Balance—total tax less sellers discount . . . . . . . . . . . . . . . . $
7. Penalty for late payment—10% of item 4 .
(.10 x line 4) . . . . . . . $
8. Total tax and penalty . .
(line 6 + line 7) . . . . . . . . . . . . . . . . $
9. 10% per annum interest on tax and penalty . . . . . . . . . . . . . . $
(Line 8 x .10 ÷ 365 x number of days late)
10. TOTAL TAX, PENALTY, AND INTEREST. . . . . . . . . . . . $
____________________________________________________________________________________
Please remit the amount shown on Line 10 to: Treasurer, Town of Culpeper
400 South Main Street, Culpeper VA 22701
IF PAID AFTER THE DUE DATE A PENALTY OF 10% OF THE TAX AND INTEREST AT THE RATE OF 10% PER ANNUM WILL BE
COMPUTED AND DUE AND PAYABLE IN ACCORDANCE WITH SECTIONS 23-109 AND 23-111 OF THE TOWN CODE.
_____________________________________________________________________________________
DECLARATION OF SELLER:
I hereby swear or affirm that the amounts listed above are true, correct, and complete to the best
of my knowledge and belief for the period stated above.
Date __________________________ Signature ___________________________________
PRINT NAME _______________________________
Phone No. _____________________ Title ________________________________________
_____________________________________________________________________________________
Office use only:
Received by Treasurer’s Office: Amount Paid: ______________ Date: _____________ Postmark Date: _________ Initial:_____________
Refund/adjusted amount: _________________ Adjusted Total Tax, Penalty and Interest: ______________________
Clerk’s Office verification: Date: _______________________ Initial: ______________
Rev. July 2016
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