Form Center

2. **THIS FORM IS TO BE PRINTED OUT ONLY**
3. Room Occupancy Tax Remittance Form
5. Name of Hotel/Motel*
6. Tax ID No.*
8. Address1
10. Address2
12. City
13. State
14. Zip
16. Quarterly Payment

    1. January 1 - March 31, due on or before April 20
    2. April 1 - June 30, due on or before July 20
    3. July 1 - September 30, due on or before October 20
    4. October 1 - December 31, due on or before January 20
17. *File this return with your remittance for the amount of tax due for the reporting period, on or before the due date (see schedule above). The failure to file a return or pay the amount due within the time required by law shall be subject to a penalty of 5% of the amount due per month or any fraction of a month to a maximum of 25% for each year; plus interest at the rate of 1% of such tax for each month of delay or fraction of a month after such return was required to be filed or such tax became due.
19. Make remittance payable and mail return to: CITY OF WHITE PLAINS-DEPT OF FINANCE 255 Main Street, White Plains, NY 10601
21. Certification of Taxpayer: Under penalties of perjury, I declare that I have examined this return, and to the best of my knowledge and belief, it is true, correct and complete.
23. Signature___________________________________
25. Title_______________________________________
26. Date___________________________________
Leave This Blank:


29. Print Only

* indicates a required field