Zip State

This report is for the month/quarter ending

Business Name, Address & Contact Information

Bell CountyReport of Hotel Occupancy Tax

I declare that the information contained in this Hotel Occupancy Tax Report is accurate to the best of my knowledge and belief.

Hotel Occupancy Tax Calculation

(Pursuant to Bell County order #291/15 dated August 24, 2015.Affidavit

Telephone Number

Business Name (DBA)

Owner Name

Location Address

Mailing Address

State Taxpayer Number

Contact Person

Email Address

State Zip

City

Remit to: Bell County, TexasPlease remit the following:

7

PaymentPayment is due on the 20th of the following month. A Penalty will be assessed if postmarked after the due date.

Treasurer's Office

DateSignatureDuly Authorized Agent (Print Name) Title

Total Gross Receipts for the Month/Quarter

Less Receipts Exempted from Tax (all exemptions must be validated by a signed hotel occupancy tax exemption certificate)

P.O. Box 812Belton, Texas 76513

(1) The amount due in the form of a check or money order(2) An original of this report

Net Tax Due (line 5 minus 6 a plus 6c plus 6d)

Total Taxable Receipts (Subtract line 2 from line 1)

Hotel Occupancy Tax Rate

Hotel Occupancy Tax Due (line 3 multiplied by line 4)

Discount or Penalty and Interest

Less discount if postmarked by Due Date (line 5 multiplied by 1%)

6

6a

6b

6c

6d

1

2

3

4

5

2%

Plus penalty if postmarked after Due Date (line 5 multiplied by 5%)

Plus additional penalty if postmarked more than 31 days after Due Date (line 5 multiplied by 5%)

Plus interest if postmarked more than 60 days after Due Date (see instructions)

City