Fillable Occupancy Tax Waiver Form 2016-03-31

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Occupancy Tax Waiver Form 2016-03-31

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Country of origin: US
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HOTEL/MOTEL TRANSIENT OCCUPANCY TAX WAIVER
(EXEMPTION CERTIFICATE FOR STATE AGENCIES)
STATE OF CALIFORNIA
HOTEL / MOTEL NAME
TO:
DATE EXECUTED
HOTEL / MOTEL ADDRESS
(Number, Street, City, State, ZIP Code)
OCCUPANCY DATE(S)
$
, CALIFORNIA
I hereby declare under the penalty of perjury that the foregoing statements are true and correct.
HEADQUARTERS ADDRESS
STATE AGENCY NAME
TRAVELER'S NAME
(Printed or Typed)
AMOUNT PAID
(City)
TRAVELER'S SIGNATURE DATE SIGNED
STD. 236 (NEW 9-91)
EXECUTED AT:
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.
HOTEL/MOTEL OPERATOR: RETAIN THIS WAIVER FOR YOUR FILES TO SUBSTANTIATE YOUR REPORTS.
PARTICIPATION BY OPERATORS IS STRICTLY VOLUNTARY
HOTEL/MOTEL TRANSIENT OCCUPANCY TAX WAIVER
(EXEMPTION CERTIFICATE FOR STATE AGENCIES)
STATE OF CALIFORNIA
HOTEL / MOTEL NAME
TO:
DATE EXECUTED
HOTEL / MOTEL ADDRESS
(Number, Street, City, State, ZIP Code)
OCCUPANCY DATE(S)
$
, CALIFORNIA
I hereby declare under the penalty of perjury that the foregoing statements are true and correct.
HEADQUARTERS ADDRESS
STATE AGENCY NAME
TRAVELER'S NAME
(Printed or Typed)
AMOUNT PAID
(City)
TRAVELER'S SIGNATURE DATE SIGNED
STD. 236 (NEW 9-91)
EXECUTED AT:
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.
HOTEL/MOTEL OPERATOR: RETAIN THIS WAIVER FOR YOUR FILES TO SUBSTANTIATE YOUR REPORTS.
PARTICIPATION BY OPERATORS IS STRICTLY VOLUNTARY
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Occupancy Tax Waiver Form 2016-03-31

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Completed 19 February 2020

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