Lodger’s Tax Payment Form Business/Lodge Name* Certificate #* Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Address* Same as Mailing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Current Date* MM slash DD slash YYYY Report Month*Select a MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberReport Year*Select a Year2018201920202021202220232024HiddenDecemberHiddenDecember Text HiddenYearLate Date Month Day Year Gross Rent for Lodging*Amounts received for rooms rented to vendees who have been a permanent resident of the premises for at least 30 consecutive days.*Amounts received from room rent less than $2.00/day*Total Gross Taxable Rent for Lodging*Lodgers Tax Remitted (5% of Receipts)*Hidden10% of totalLate Fee $100$100 or 10% of total, whichever is greater. Payment is late as of the 25th of the month following the reporting month at midnight mountain time.Late Fee 10% of total$100 or 10% of total, whichever is greater. Payment is Late as of 25th of the month following the reporting month at midnight mountain time.TotalTotal Rental Units in Facility:*Number of Units Available per Month:*Number of Times Units were Rented*PENALTY FOR FAILURE TO MAKE PAYMENT OF TAX WHEN THIS REPORT IS DUE IS: The greater of 10% of the amount that was not duly remitted or $100.00. Under penalty of purjury, I declare that I have examined this report and to the best of my knowledge and belief it is true, correct and complete.SignatureName* First Last Title TelephoneEmail After submitting this form you will be redirected to our payment processor to pay the amount: 1