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RETURN OF TAX ON OCCUPANCY HOTEL/MOTEL ROOMS (Pursuant to Local Law 1 of 2002, as amended by Local Law 1 of 2009 and Local Law 4 of2013) QUARTERLY PAYMENT PERIOD: DUE ON OR BEFORE: • December 1st - February 28th • March 1st - May 31st • June 1st - August 31st • September 1st -November 30th March 201h June 20th September 20th December 20th ESTABLISHMENT/OWNER INFORMATION: Name of Establishment: Name of Owner: Owner's Address: (Street) TYPE OF ESTABLISHMENT: (City) 0Hotel 0Motel 0Bed & Breakfast 0Condo 0Yurt/Hut 0Private Residence 0Vacation Rental Oother OTHER INFORMATION: Number of Rooms: Sales Tax ID No.: YEAR: (State) (Zip) Ocampsite Date Establishment opened in Cortland County: COMPUTATION OF TAX: A. B. Income from Occupancy of Rooms LESS: Exempt Income 1. Occupants from exempt Organizations $ 2. Permanent Residents $ 3. Add Lines B 1 and B2 Net Taxable Income (Line A less minus Line B3) Tax Due of Line C) Penalty and Interest Prior Underpayment (Bl) (B2) C. D. E. F. G. Prior Overpayment ( as approved by Chairman of the Legislature) H. Total Tax Due (Line D plus Line E plus Line F minus Line G) $ $ (B3) $ $ $ $ $ $ This return must be filed, with your payment and must be received by Cortland County Office of Budget and Finance no later than 20 days following the fmal date of the return to avoid the imposition of penalties. MAKE CHECK PAY ABLE TO: Cortland County Treasurer MAIL TO: Cortland County Office of Budget and Finance 60 Central Ave., Room 132 Cortland, NY 13045 CERTIFICATION OF TAXPAYER: Under penalties of perjury, I hereby certify that I have examined this return, including accompanying schedules and statements, and to the best ofmy knowledge and belief, it is true, correct and complete. Signature of Authorized Officer Title Type or Print Name of Authorized Officer Date