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GREENE COUNTY, GEORGIA HOTEL-MOTEL OCCUPANCY TAX Hotel/Motel Name: Address: Contact Name: Phone: Fax: E-Mail: This report is due and payable on the 20th day of the month following the month of collection. If the 20th day falls on other than a business day, the report shall be due on the following work day. Taxpayers not filing this report on or before the due date shall not be entitled to the operator collection fee and any tax due shall bear interest at the rate of 3/4% per month or portion of the month until said tax is paid. Report for the month of: Gross Room Rent Less Exempt Rent Net Taxable Rent Amount of Tax at 5% Net Amount Due I DECLARE UNDER PENALTIES PRESCRIBED THAT THE INFORMATION CONTAINED IN THIS DOCUMENT IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. Signed: Title: Please remit payment to: Greene County Board of Commissioners Attn: Finance Department 1034 Silver Drive, Suite 201 Greensboro, Georgia 30642 (706) 453-7716 Less 3% of Tax as Collection Fee