| BusinessName: |
| Owner : |
| Address:
City
St Zip |
| Phone/Fax/E-mail : |
| Certificate _________________(#assigned by county) |
| 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 Check Amount (one check is sufficient) |
$ |
$ |
$ |
|
| 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. |
| |
| Signature_____________________________Title_______________Date:________ |
| |
| A copy of this form must accompany your monthly tax return: |
| SUBMIT BY THE 25TH OF THE MONTH FOLLOWING THE END OF THE QUARTER |
| Make check payable to: SUSQUEHANNA COUNTY TREASURER |
| MAIL TO: |
| Susquehanna County Treasurer |
| PO BOx
218 Montrose, Pa 18801-0218 |
| Fax: 570-278-3372 Phone: 570-278-4600 OfficeUseOnly: Date Pd:
Ck#:
Receipt# |
