TOWNOFMIDDLEBURG,VIRGINIA
REPORTOFTRANSIENTLODGINGTAXCOLLECTED
FORQUARTERENDING:____________________________,_____________
Instructions:Filloutthisformandsendto:TownofMiddleburg,P.O.Box187,Middleburg,VA20118
(Pleasemakeacopyofthecompletedformforyourrecords.)
Reportandpaymentaredueonorbeforethetwentieth(20
th
)dayforthemonthfollowingthequarterduringwhich
thetaxwascollected.Checksormoneyordershouldbemadepayabletothe“TownofMiddleburg”.
1. NameofHotel,Motel,Inn,OtherLodgingPlace:_____________________________________________
_____________________________________________________________________________________
2. StreetAddress:________________________________________________________________________
MailingAddress:_______________________________________________________________________
3. TotalReceiptsfromRoomRental,Lodging…………………………………………………………$__________________
4. LessExemptReceipts:
a. ReceiptsFromGuestsObtainingRoom,Rental,LodgingforaPeriodof
Ninety(90)ConsecutiveDaysorMore……………………………………………………$__________________
b. ReceiptsfromOfficialsandEmployeesonOfficialBusinessfortheUnited
States,theCommonwealthofVirginia,theCountyofLoudoun,orthe
TownofMiddleburg……………………………………………………………………………….$__________________
5. TotalExemptReceipts(4a+4b)…………………………………………………………………………$__________________
6. TotalTaxableReceiptsthisReportQuarter(SubtractLine5from3)……………………$__________________
7. AdjustmentstoPriorQuarter’sReport:(Intheeventtaxablereceiptsforprior
Quarter’sreportwereover‐orunder‐reported,usethislinetodecreaseor
Increase,ascasemaybe,yourtotaltaxablereceiptsreportedonline6above.
Iftheadjustmententeredonthislineistobesubtractedfrom6,indicatewith
Symbol‘CR’nexttoamountentered)………………………………………………………………..$_________________
8. TotalTaxableReceiptsSubjecttoTaxthisReport(Line6plusorminusLine7).. $__________________
9. MiddleburgTransientRoomTaxDueThisReport(5.0%)ofamountonLine8…. $__________________
10. NorthernVirginiaRegionTransientOccupancyTax(2.0%)ofamountline8…….. $__________________
11. Penalties(forlatefiling)at10.0%......................................................................... $__________________
12. Interest10.0%perannum(assessedbyTownonunpaidbalances)………………….. $__________________
13. TOTALDUE(TotalofLines9‐12):………………………………………………………………………. $__________________
14. SignatureofOwner,Partner,orOfficer:
Signature:________________________________________________Date:______________________
Contactphon
enumber:_________________________________________________________________
*TownofMiddleburg*10WestMarshallStreet*P.O.Box187*Middleburg,VA20118*540‐687‐5152*
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