Remittance Of Tax - Short Term Rental Tax Form June 2004
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1OFFICE OF THE COMMISSIONER OF THE REVENUE
County of Stafford, Virginia
Phone (540) 658 - 4132
Remittance of Tax
Short Term Rental Tax
Account Name
Telephone:
Mailing Address
Remittance for Quarter Ending
City, State & Zip
1. Gross Receipts
$ ........................................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Less Allowable Deductions (Attach List)
$ ........................................
3. Taxable Balance
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ........................................
4. Tax on Item 3 at
. . . . . . . . . . . . . . . . .
$ ........................................
1.00 %
4a. Not Applicable
5. Balance
(Item 4 - Item 4a [if applicable])
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ........................................
10.00 %
6. Penalty for Late Payment on Item 5 at
. . . . . . . . . . . . . . . . .
$ ........................................
7. Balance (Item 5 + Item 6)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ........................................
$ ........................................
10.00
8. Interest (per annum) for Late Payment (Item 4a must be 0) on Item 7 at
%
. . . . . . . . . . . . . . . . .
9. Total Due [Tax, Penalty and Interest] (Item 7 + Item 8)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ........................................
10. Amount Paid (Check # .................................)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ........................................
DECLARATION OF SELLER
I hereby swear or affirm that the amounts listed above are true, correct and complete to the best of my knowledge and belief for the
period stated above.
Date :
.....................................
Signed by :
........................................................................................
Phone Number :
.....................................
Title :
........................................................................................
INSTRUCTIONS :
MAKE CHECK PAYABLE TO: STAFFORD COUNTY TREASURER
Mail completed form, with check, on or before 20th of month following period end.
To:
SCOTT A. MAYAUSKY
Commissioner of the Revenue
P.O. Box 98
Stafford, Virginia 22555-0098
For Office Use Only -
55
RCS Menu Code:
Account:
Name and Address: _______________________________________
_______________________________________
Telephone:
_______________________________________
Remittance for Quarter Ending
Check #:
...............................
Amount $: .....................................................................
.........................................
Received by:
.................................................................................................................
Date received in Office
Office of Stafford County Commissioner of the Revenue
Form Last Revised: 06/03/2004
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