TOWN OF HILTON HEAD ISLAND 
                                      REVENUE AND COLLECTIONS DIVISION 
                              One Town Center Court, Hilton Head Island, SC 29928 
                                      Phone (843) 341-4677                         Fax (843) 341-4637 
                              You can pay online at: www.hiltonheadislandsc.gov 
 
                                                    Hospitality  Tax Payment              Form 
 
                                                                        ACCOUNT          #: 
 NAME                                                                   PHYSICAL ADDRESS 
 MAILING ADDRESS                                                                                      , 
                       , 
                                                     
                                                                        PHONE NUMBER: 
 
 Important:  A  tax   payment   form   must   be  filled   out   and   submitted  each   quarter.   Additional   forms   can   be   obtained       through 
 www.hiltonheadislandsc.gov. 
 
 FILING STATUS: Circle one... Monthly / Qtrly        PAYMENTFORPERIODMONTH                            QUARTER:1st,            2nd, 3rd,  4th  YR:                            
 
 IS THE BUSINESS SOLD?  If yes, please complete the following information:               Date Sold: 
 
      NEW OWNER NAME 

      ADDRESS: 

      CITY/STATE/ZIP: 

      PHONE NUMBER 
 
                                                                                                        T    FOR OFFICE USE ONLY                   T 
                              HOSPITALITY TAX                                                        
                                                                                                     
                                                              Report in Whole      Dollars          Postmark 
 
 1. Gross Proceeds: Food and Beverages                                                      XX      CK#                                                                    
                                                                                   •      
                                                                                    
                                                                                                    Receipt#                                                              
                                                                                    
 2.  Hospitality Tax                  Line 1 x 2%* (.02)  ...                      •      
                                                                                                    Hospitality Tax 
                                                                                    
 3. Penalties are calculated as follows: 5% of the 
      unpaid  amount…for each month or portion  thereof   ...                      •                Penalty 
                                                                                    
      after the due date until paid.  Additionally,                                                  
      delinquent  businesses may be subject to a $1092.50                                           Amt Received 
      municipal summons.                                                                             
                                                                                                    Adjustment 
 4. Total Hospitality Tax Due (Add Lines 2 and 3)                                   
                                                                                   •      
                                                                                                     
                                                                                                    BalDue                                                                
 
                                                                                                    RefundDue                                                               
                                                                                                     
 IMPORTANT ...  Enclose payment with    report. Please do not staple                                Source:                   B    or  C 
                 This return becomes DELINQUENT if it is postmarked after the 20th day following the end of the               period 
 I hereby certify that the information contained on this report is true and accurate to the best of my knowledge and belief 
 
 Name:                                                                  Signature:                                                                                            
 
 *Make  additional copies for each              quarter as needed.