Hotel/motel Transient Occupancy Tax Waiver (Exemption Certificate For State Agencies)
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STATE OF CALIFORNIA
HOTEL/MOTEL TRANSIENT OCCUPANCY TAX WAIVER
(EXEMPTION CERTIFICATE FOR STATE AGENCIES)
STD. 236 (NEW 9-91)
HOTEL/MOTEL OPERATOR: RETAIN THIS WAIVER FOR YOUR FILES TO SUBSTANTIATE YOUR REPORTS.
DATE EXECUTED
PARTICIPATION BY OPERATORS IS STRICTLY VOLUNTARY
HOTEL / MOTEL NAME
TO:
HOTEL / MOTEL ADDRESS (Number, Street, City, State, ZIP Code)
This is to certify that I, the undersigned traveler, am a representative or employee of the State agency
indicated below; 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 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.
AMOUNT PAID
OCCUPANCY DATE(S)
$
STATE AGENCY NAME
HEADQUARTERS ADDRESS
TRAVELER'S NAME (Printed or Typed)
I hereby declare under the penalty of perjury that the foregoing statements are true and correct.
(City)
EXECUTED AT:
TRAVELER'S SIGNATURE
DATE SIGNED
, CALIFORNIA
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