Monthly Report of Collections
of $2.00 Additional Tax of Transient Occupancy

Instructions:
This form and payment in addition to the monthly Transient Occupancy form must be submitted on or before the 20th of the month following the month being reported.

Transient Occupancy ($2 Addl Tax) Business I.D. No.  
Account No.   
Location Bethel Bruton Grafton Nelson
Business Name (if applicable)
Last Name (if applicable)      First Name     
Mailing Address
City     State     Zip
Trade Name
Physical Address
City     State     Zip
Business Phone Number


1. Total Number of Rooms (per night rented) for Month of        January February March April May June July August September October November December
2. Tax ($2.00 per night, per room)                                                  
3. Exempt (Transient from prior months filing turned Non-Transient)    
4. Total Tax (Line 2 Less Line 3)                                                    
5. Penalty for Late Filing (10% of Line 4)                                        
6. Penalty for Late Payment (10% of Line 4 & 5) $10.00 min.            
7. Interest @ 10% per annum on Line 4 & 5                                   
8. Total Tax, Penalty and Interest                                             
                  (Sum of Lines 4, 5, & 6)


Method of Payment:
On-line (E-check)    (To pay on-line click  here.) 
By mail  (Make checks payable to: Treasurer, County of York) *

*Please Note: If submitting payment by mail, you must enclose a copy of this form with the monthly Transient Occupancy form as well as fill in the boxes below for the amount of payment enclosed and check #.

Amount of payment enclosed     Check #


Declaration of Seller:
I hereby swear or affirm that the amounts listed are true, correct and complete to the best of my knowledge and belief for the period stated. By placing your initials in the appropriate box, it will be equivalent to your signature.

Taxpayer Initials     Date of Report


**This form and payment in addition to the monthly Transient Occupancy form must be submitted on or before the 20th of the month following the month being reported.**

You may wish to print a copy for your records.

Please verify your information and