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RETURN OF TAX ON OCCUPANCY OF HOTEL/MOTEL ROOMS (Pursuant to Chapter 533 of the Laws of 1994 of the State of New York) State of New York 1st Quarter due on or before April 20th County of Cayuga 2nd Quarter due on or before July 20th County Treasurer’s Office 3rd Quarter due on or before October 20th 4th Quarter due on or before January 20th For Quarter Covering Dates from to Name CERTIFICATE OF AUTHORITY Address No. Zip Code Name of Hotel/Motel IF THIS RETURN REPRESENTS THE LAST QUARTER OF BUSINESS WRITE “FINAL” HERE Type of Establishment: (check one or indicate other with description) Hotel Motel B& B Other Range of Room Rates to Business Activity: Number of Rooms Business Started Gross Income from occupancy of rooms Computation of Tax: A – Taxable Room Rentals B – Less: Refunds and Other Credits C – Net Taxable Rentals (line A minus line D – Tax Due of line E – Penalty F – Total **Penalty of 5% per month is to be added for late filing, unless reason is given for unavoidable delay. Additional interest will be imposed by the County Treasurer for late payment at a rate of 1% per month in accordance with Section 20 of Local Law #3 of 1994 – Room Occupancy Tax Law CERTIFICATION OF TAXPAYER Make remittance payable and mail I hereby certify that this report, including any schedules with this return to: to the best of my knowledge and belief a true and Cayuga County Treasurer complete report. 160 Genesee Street, 5th Floor Auburn, NY 13021 (Name of Business or Taxpayer) Please make a copy of this return for your records. (Signature of Agent or Officer of Corporation, etc.)