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2. Business Name*
4. Taxpayer Number*
6. Filing Date
   Filing Date

   Filing Date
7. Due Date
   Due Date

   Due Date
9. Email Address*
11. Daytime Phone Number*
13. Taxpayer Name*
15. Outlet Trade Name and Location Address
17. Location Capacity
19. Outlet Number
21. Total Room Receipts
23. Total Taxable Receipts
27. Calculations
29. Total Room Receipts

    (Item 4 from this and all supplemental pages)

31. Total Taxable receipts

    (Item 5 from this and all supplemental pages)

33. Amount of Tax
35. Apply Penalty

    1. Yes
    2. No

    (After 20th of the month 15% of the total amount of taxes owed)

37. Apply Interest

    1. Yes
    2. No

    (10% per annum beginning 60 days after due date.)

39. Total Amount Due and Payable
41. Signature*
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field