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Cortland County Office of Budget and Finance 60 Central Ave., Room 132; Cortland, N.Y. 13045 Peggy L. Mousaw, CMFO, Director [EMAIL REDACTED] Phone: (607)758-5587, Fax: (607)758-5512 CERTIFICATE OF REGISTRATION Application for Authority to Collect Room Occupancy Tax in Cortland County Business Name: Location of Business: Mailing Address: ( if different than above) Federal Tax Identification# or Social Security#: D Attach copy NYS Certificate of Authority D Attach copy Owner of Record: # of Rooms: Contact Name: Phone Number: Contact E-Mail: Business Phone Number: Business Fax: Website: Date business opened in Cortland County: Type of Establishment: D Hotel D Motel D Bed & Breakfast D Vacation Rental D Campsite D Condo D Yurt/Hut D Private Residence D Other Type of Ownership: D Sole Proprietor D Partnership D Corporation D Other I hereby certify that the statements made herein have been examined by me and are to the best of my knowledge and belief is true, correct and complete. I understand that I am required to collect 5% of room rate for eligible rentals that are less than 30 days in occupancy, said funds are to be submitted to Cortland County quarterly via per attached submittal form and I am subject to paying a 10% (ten) penalty plus interest for late or non filings. I am aware that I am subject to audit up to three years by Cortland County from date of rental and that I am required to notify Cortland County within 10 (ten) business days of dissolution or sale of business regarding same. Signature of Authorized Officer Title Type or Print Name of Authorized Officer Date