Hotel/Motel Transient Occupancy Tax Waiver

Exemption Certificate for State Agencies

DATE:

TO:

ADDRESS:

This is to certify that I, the undersigned, am a representative or employee of the state agency indicated below: that the charges for the occupancy at the above establishment on the date(s) set forth below have been, or will be, paid for the State of California; and that such charges are incurred in the performance of my official duties as a representative or employee of the State of California.

DATE(S) OF OCCUPANCY:

AMOUNT PAID:

STATE AGENCY: Palomar Community College District

1140 West Mission Road

San Marcos, CA 92069-1487

(760) 744-1150

I HEREBY DECLARE UNDER PENALTY OF PERJURY THAT

THE FOREGOING STATEMENTS ARE TRUE AND CORRECT.

Executed at San Marcos, CA

______________________________________

(Employee Signature and Date)

HOTEL/MOTEL OPERATOR:

RETAIN THIS FORM FOR YOUR FILES

TO SUBSTANTIATE YOUR REPORTS