TOWN OF HILTON HEAD ISLAND 
                                              REVENUE SERVICES 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.                                                                            
 
 4. Total Hospitality Tax Due (Add Lines 2 and 3)                                                           Adjustment 
                                                                                           •      
                                                                                                             
                                                                                                            BalDue                                                                

                                                                                                                RefundDue                  
                                                                                                             
                                                                                                            Source:            B    or  C 
 IMPORTANT ...  Enclose payment with          report. Please do not staple
         This return becomes DELINQUENT if it is postmarked after the 20th day following the end 
     of the   period.  *Make  additional copies for each     quarter as        needed. 
 
 I hereby certify that the information contained on this report is true and accurate to the best of my knowledge and belief 
 
 Name:                                                                          Signature: