Room Tax Form

Business Name:

Owner :

Address: City: St: Zip:

E-mail : PhoneFax

Please Fill in all information fields Your Certificate Number

Reporting Period:	Month	Month	Month
Gross Receipts:	$	$	$
Exempt Receipts-Over 30 Days	$	$	$
Taxable Receipts	$	$	$
Tax Collected @ 3%	$	$	$
Tax Due	$	$	$
Late Fee @.75% Per Month	$	$	$
Total Payment Due	$	$	$
Total Payment Amount			$

This tax is to be collected by the operator of each facility from each patron who rents a room. Each operator is required to file a tax return and remit tax due on or before the 25th day of the month following the end of each quarter for which the tax is levied. If there is no tax due for a given period, file return indicating "NO TAX DUE" on the tax due line.

I hereby certify that this return has been examined by me and that the information herein is true, correct and complete to the best of my knowledge.

SignatureTitle Date:

Link to SameDayPay for online payment. You must link to Same Day Pay to make payment

Fees are $3.00 for electronic check. 2.35% for credit card transactions. Visa & Master Card, Amex & Discover accepted.PLEASE NOTE:_COMPANY IS FIXING ENTRY OF CERTIFICATE NUMBER-will advise when corrected

SUBMIT BY THE 25TH OF THE MONTH FOLLOWING THE END OF EACH QUARTER

Catherine R Benedict, Susquehanna County Treasurer

PO BOX 218 Montrose, Pa 18801-0218 Fax: 570-278-3372 Phone: 570-278-4600 X131