1. Name of Hotel / Motel 2. NYS Sales Tax Identification Number
3. Name of Operator (only if different from above) 4. County Tax Occupancy Number
5. Street Address 6. P.O. Box (if any) 7. Town/Village 8. Zip code
10. Name of Contact Person 11. Title or Position 12. Phone Number
13. Year Monthly Quarterly
Month 14. Gross Monthly Income From Occupancy
of Rooms During Period Covered By Return
15. Less Tax Exempt
Sales By Month
16. Net Monthly Taxable Income
From Occupancy of Rooms
Jan. $ -$ $
Feb. $ -$ $
Mar. $ -$ $
Apr. $ -$ $
May $ -$ $
Jun. $ -$ $
Jul. $ -$ $
Aug. $ -$ $
Sep. $ -$ $
Oct. $ -$ $
Nov. $ -$ $
Dec. $ -$ $
Total Net Yearly Taxable Income
17. County Occupancy Tax Due (4% of line 16) $
18. Penalty (5% of line 17 if tax not paid within 20 days of end of period
covered this return) Apply
+ $
19. Interest (1% of line 17 for each month or fraction thereof if tax not paid
within 30 days of period covered by this return – no interest on first 30 days) Months late ____
+ $
Under the penalties of perjury, I hereby declare that I have examined this return and the information
contained herein, and to the best of my knowledge belief the same are true, correct and complete.
Signature Print Name and Title Date
Warren County Treasurer
1340 State Route 9
Lake George, NY 12845
Warren County Occupancy Tax Return
Please read instructions on reverse side
Line 14. Enter the total receipts from room rentals. Include receipts from permanent guest(s) - person(s) who
occupy or
Rent any room/unit for at least 30 consecutive days - and from tax exempt gu
Line 15. Enter total amount of tax exempt and permanent guest receipts. Keep copies of all tax exempt certificates and
Line 16. Subtract Line 15 from Line 14. This is the amount on
which y
tax is to be computed.
Line 17. Enter 4% of Line 16 to compute the tax.
Line 18. Enter 5% of Line 17 if the retu
rn is not filed or the t
ax due is not paid within 20 day
s of period covered by this return.
Line 19. Enter 1% of Line 17 for each mo
nth or fraction of a month your payment is past due. No interest is to be
calculated on the first 30 days
. Example 1 - if payment of the tax is due on March 1
and is paid on March 31
no interest is due (but the 5% penalty in line 18 must be paid). Example 2 - if the tax is due March 1
and is not
paid until April 2
, no interest is due for the period in March 1-31, but 1% of the amount in line 17 must be
included and paid for the period of April 1-2.
Line 20. Enter the total of Lines 17, 18 and 19. This is t
he gross amount due Warren County. Make check(s) payable to
Warren C
ounty Treasurer” and mail with this ret
urn to: Warren County Treasurer, 1340 State Route 9, Lake
George, New York 12845.
Nature of Tax: The tax is imposed upon the occupancy of any hotel or motel accommodations in Warren County. The term “hotel or
motel” means any facility
providing lodging on an overnight basis and includes a bed and breakfast facility, inn,
housekeeping cottages with four or more units, and tourist facilities.
Persons Subject
To Tax: The occupant, lessee, or tenant of an
y such hotel or motel accommodation is liable f
or payment of the tax. The tax is
collected by the
owner of the hotel or motel room occupied or if the owner is
not operating the hotel or motel and being paid the rent for the room occupied, then any other
person entitled to be paid the rent or charge for the
hotel or motel room occupied, including but
not limited to the proprietor, lessee, sublessee, mortgagee in possession, licensee or any
person otherw
ise operating such hotel or motel.
Exemptions: 1. Occupancy for 3
0 consecutive day
s or more - perm
anent guests.
2. The State of New York, or any public corporation (including one created pursuant to agreement or compact wi
another state or the Dominion of Canada) improvement district or other political subdivision of the state.
3. The United States of America, or a department or agency thereof.
4. A tax-exempt corporation or association, or trust, or
community chest, fund or foundation, organized and
exclusively for religious, charitable or educational purposes, or for the prevention of cruelty to children
or animals, and no part of the net earnings of which inures to the benefit of any private shareholder or individual
and no substantial part of the activities of which is carrying on propaganda, or otherwise attempting to influence
Basis and Rate The tax is 4% of the per diem rent
al rate for each room or unit.
of Tax:
Due Date For 20 days
after the close of the period covered by th
e return. Returns are required to be filed for the Fil
ing Return(s)
& Payment of Tax:
Penalty: 5% of the total ta
x due for failure to file the return or pay the tax within 20 days of the close of the period covered b
y the
Interest: 1% per month o
r fraction thereof for late payment, with the first 30
days after the due date being inter
est free.
other proof of exemption, as well as all evidence of all permanent guest(s) including names, residence addresses, dates of
occupancy, and rate charged. All records must be available for inspection and examination at any time upon demand by
the Treasurer, and should be preserved for a period of at least six (6) years.