NAME OF BUSINESS:________________________________________________________ 

MAILING ADDRESS:_________________________________________________________ 

TELEPHONE NUMBER OF BUSINESS:      ___________________________________  

HOME ADDRESS OF OWNER: *                    _________________________________________________

HOME TELEPHONE NUMBER OF OWNER: *______________________________________________                             

1.  Lodging and/or Meals charges subject to Tax                       $

2.  Tax on lodging and/or meals (5% of line 1)                           $

3.  Subtract 4% collection fee from line 2                                  $

DO NOT subtract collection fee if paying after due date.

TOTAL TAX DUE: (line 2 minus line 3)                                      $

PENALTY (10% OF TAX DUE)                                                $

Total due if paid after due date                                                 $

PENALTY APPLIES IF PAID AFTER THE LAST DAY OF THE MONTH FOLLOWING MONTH

BEING REPORTED

SIGNATURE OF BUSINESS REPRESENTATIVE: 

_____________________________________________________

PLEASE MAKE CHECK PAYABLE TO: 
TOWN OF DAMASCUS and mail to:
PO Box 576,   
Damascus, VA 24236-0576

DATE RECEIVED BY TREASURER’S OFFICE_______________________________________

 *Home address and telephone number of owner is needed in case of an emergency at times the business is not open.

 FORM MUST BE FILED EVERY MONTH.  IF NO MONIES ARE RECEIVED, A FORM SHOULD STILL BE FILED SHOWING “ZERO” DUE.