Guest Name Lodging Provider Name (Seller)
Address Address
City State ZIP Code City State ZIP Code
Only employees of the U.S. Government, Idaho state government, a local government agency in Idaho, and the
qualied organizations listed in the instructions can claim a tax exemption on lodging. These employees must pay with
their organization’s qualifying credit card. Employees can’t claim the exemption if they pay the charges with a personal
credit card, personal funds, or from expense reimbursements.
Complete the section below that applies to you. To protect credit card information, enter your card number using only
the blank spaces that correspond with the numbers from your card. You must complete this form at the time of sale for
the exemption to apply.
1. U.S. Government
I’m an employee of:
Name of Agency
Choose GSA
SmartPay Method
Card Description
Integrated Card:
Integrated cards are GOLD and labeled as “U.S. Government Tax Exempt.” All charges are
billed directly to the agency and qualify for exemption.
Purchase Card:
Purchase cards are RED and labeled as “U.S. Government Tax Exempt.” All charges are billed
directly to the agency and qualify for exemption.
Tax Advantage Card:
Tax Advantage cards are SILVER and labeled as “U.S. Government CBA Tax Exempt.” All
lodging charges are billed directly to the agency and qualify for exemption.
Travel Card:
Travel cards are BLUE. The rst four digits of the card number will be: 4486, 4614, 4615, 5565,
or 5568. Travel cards with the sixth digit of 6, 7, 8, 9, or 0 are billed directly to the government
agency and qualify for exemption. Charges to travel cards with the sixth digit of 1, 2, 3, or 4
don’t qualify for exemption.
Enter Credit Card Number:
X X X X X X X
U.S. Government employees paying with a credit card other than described above are subject to tax on all lodging and room-related charges.
2. Idaho State Government
(School employees must complete the “Idaho Local Government or Qualied Organization” section below)
I’m an employee of:
Name of Agency
Qualifying cards are VISA® cards issued by Bank of America and are labeled as “Tax Exempt.” The cards display the
name of the agency and usually the name of the state employee. Lodging charges billed to these cards qualify for
exemption. Charges to other cards, such as Diners Club® that include the state agency and an employee name, are billed
directly to the employee and don’t qualify for the exemption.
Enter Credit Card Number:
X X X X X X X X
3. Idaho Local Government or Qualied Organization
(See form instructions for a description of local government agencies and qualied organizations)
Charges to cards that a local government agency or qualied organization pays directly qualify for the exemption. Charges
to cards that the employee is responsible for or must be reimbursed for don’t qualify for the exemption.
I’m an employee of:
Name of Agency or Qualied Organization
By signing this form, I certify that the statements I made on this form are true and correct. I know that submitting
false information can result in criminal and civil penalties.
Guest Signature Driver’s License Number and State of Issue Work Phone Number Date
EFO00164 10-05-2018
Page 1
Enter Credit Card Number:
X X X X X X X X
Type of Card:
American Express®
Diner’s Club® Discover® MasterCard®
VISA®
Other
Form ST-104HM
Tax Exemption on Lodging Accommodations
