Wyoming Dept of Revenue
                           Wyoming Lodging Tax                                                      122 W 25th St, 2W
                                                                                  Cheyenne, WY 82002-0110
     Form 41-3             Supplement for Lodging Vendors                                                             

Please use black ink to complete form
Name                                                       Ownership RID: 
                                                           License Number: 
                                                           Report Period:                     through 

Part IV - Lodging Tax Information - Do not use dollar signs, commas or periods
(Col 1)       (Col 2)      (Col 3)                                         (Col 4)
Jurisdiction
Name Code(Use Jurisdiction Lodging Tax Rate % in           Tax Due on Lodging Services
CAPS)         Digit Code   Effect in Jurisdiction

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     Line 1. Total Tax on Lodging (Add totals in Column 4)
     Enter results here and on Part I, Line E of Form 41-1