Report and payment due on or before the 30th day of the month following
the month during which the tax was collected

Report of transient tax collected for the month of ,

1. Name of provider:
    Email Address
2. County location:
3a. Mailing address:

3b. City or Town and Zip:

4. Total receipts from rental:
5. Exempt receipts from rental:
Receipts from rentals for 30 consecutive days or more by the same person or group in the same space
6. Total taxable receipts (line 4 less line 5):
7. Adjustment to prior month's report (use this to adjust an error in line 6 of a prior month's report):
8. Total taxable receipts subject to tax (line 6 plus line 7):
9. Transient occupancy tax due (5% of line 8):

10. Provider discount (3% of line 9):

Check this box only if reported and remitted on time.
take this discount if filing late.

11. Total due (line 10 less line 9):

Please PRINT a copy of this form before you hit the submit button.