HOTEL/MOTEL TRANSIENT OCCUPANCY TAX WAIVER

EXEMPTION CERTIFICATE FOR GOVERNMENT AGENCIES

DATE:	__________________________________________________________________
NAME OF HOTEL:	__________________________________________________________________
ADDRESS OF HOTEL:	__________________________________________________________________
DATES OF OCCUPANCY:	__________________________________________________________________
AMOUNT PAID:	__________________________________________________________________
GOVERNMENT AGENCY:	__________________________________________________________________
EXECUTED AT (CITY)_____________________________________________, CALIFORNIA This is to certify that I, the undersigned, am a representative or employee of the government agency indicated above; that the charges for the occupancy at the above establishment on the dates set forth below have been, or will be paid for by the government agency; and that such charges are incurred in the performance of my official duties as a representative or employee of my government agency. I hereby declare under of perjury that the following statements are true and correct. GOVERNMENT AGENCY EMPLOYEE NAME: (PLEASE PRINT) GOVERNMENT EMPLOYEE SIGNATURE:___________________________________________ Hotel/Motel Operator: Approved by City of Riverside. Retain this for your files to substantiate your reports.