This return DUE on the 1st day                              St. Helena Parish Sheriff’s Office
     of month following period                                                 Sales Tax Division                   
     covered by the return and          
     becomes DELINQUENT                                                              SALES AND USE TAX
             on the 21st day.                                                  HOTEL/MOTEL OCCUPANCY TAX
                                                                                                                             ACCOUNT #:
                                                        PLEASE INDICATE ANY CHANGES BELOW                                    MONTH:                               YEAR:
     Date Business Discontinued                         Date Business Sold                                  Name of Purchaser

     Business Location Change                                                  Mailing Address Change

     Type (Ind. Corp, LLC, LLP, etc.)        Other                                                          Name and Phone of Contact Person

1.  GROSS SALES OF TANGIBLE PERSONAL PROPERTY LEASES, RENTALS, AND                    1.
     SERVICES AS REPORTED TO THE STATE OF LOUISIANA
                                                ALLOWABLE DEDUCTIONS                                                                                             
2.  SALES FOR RESALE OR FURTHER PROCESSING (Resale certificate on file)                 2.                                                            **NOTICE**
                                                                                                                                                     
3.  CASH DISCOUNT, SALES RETURNS AND ALLOWANCES                                       3.
                                                                                                                    COLUMN A =  Sales in unincorporated areas of the parish
4.  SALES DELIVERED OR SHIPPED OUTSIDE THIS JURISDICTION (Doesn’t apply to repairs)   4.
5.  SALES OF GASOLINE AND MOTOR FUELS                                                 5.                            COLUMN B =  Sales in Town of Greensburg
6.  SALES TO U.S. GOVERNMENT, STATE OF LA., AND ITS POLITICAL SUBDIVISIONS            6.
                                                                                                                    COLUMN C =  Sales in Village of Montpelier
7.  SALES OF FOOD PAID FOR WITH USDA FOOD STAMPS OR WIC VOUCHERS                      7.                                                                                
           OTHER DEDUCTIONS AUTHORIZED BY LAW (EXPLAIN BRIEFLY)                                                     COLUMN D =  Gross Sales for Hotel / Motel
8.                                                                                    8.
                                                                                                                                                     
9.                                                                                    9.                                                            **NOTICE**
                                                                                                                                                                 
10.                                                                                   10.
11.  TOTAL ALLOWABLE DEDUCTION             (Line 2 thru 10)                           11.
12.  ADJUSTED GROSS SALES             (Line 1 minus 11)                               12.
                                                                                                     PARISH          GREENSBURG                     MONTPELIER    HOTEL / MOTEL
                                  COMPUTATION OF TAXES                                               COLUMN A - 5%   COLUMN B - 6%                  COLUMN C - 6% COLUMN D - 2%
13.  ADJUST GROSS SALES IN EACH JURISDICTION                                          13.
14.  PURCHASE SUBJECT TO USE TAX IN EACH JURISDICTION                                 14.
15.  TOTAL (Line 13 plus line 14)                                                     15.
16.  TAX DUE   (Multiply line 15 by % shown in column)                                16.
17.  EXCESS TAX COLLECTED                                                             17.
18.  TOTAL TAX DUE  (Line 16 plus line 17)                                            18.
19.  VENDOR’S COMPENSATION        (1% of line 18) (Only if payment is not deliquent)  19.
20.  NET TAX DUE   (Line 18 minus line 19)                                            20.
                                                                                         
21.  DELINQUENT PENALTY(5% of tax for each 30 days or fraction thereof, 25% max)21.
22.  INTEREST  (12% per annum, .000329 per day)                                       22.
23.  TOTAL TAX, PENALTY & INTEREST DUE       (Sum of line 20-22)                      23.
24.  TAX DEBIT OR CREDIT (Authorized memo must be attached)                           24.
25.  TOTAL AMOUNT DUE     (Line 23 plus or minus 24)                                  25.
26.  TOTAL AMOUNT REMITTED            (Total of line 25 Columns A, B, C and D)        26.                                                           CHECK NUMBER
   I declare under the penalties for filing false reports that this return (including any accompanying schedules and statements) has been examined by me and to the best of my knowledge and belief is a true, correct and
   complete return. If the return is prepared by a person other than the taxpayer, his declaration is based on all information relating to the matters required to be reported in the return of which he has any knowledge.  
               TO AVOID PENALTIES RETURN SHOULD BE TRANSMITTED ON OR BEFORE THE 20TH DAY FOLLOWING THE PERIOD COVERED
DATE                          SIGN  HERE                                                             SIGNATURE  OF  PREPARER  OTHER  THAN  TAXPAYER REVIEWED  BY

                                                                                                                                                    Direct all mail and payments to:
                                                                                                                                                    St. Helena Parish Sheriff’s Office
                                                                                                                                                                  Sales Tax Division
                                                                                                                                                                  PO Box 1205
                                                                                                                                                                 Greensburg, LA 70441