Form 12-104 - Texas Claim For Refund Of State Hotel Occupancy Tax
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12-104
(Rev.8-09/6)
b.
TEXAS CLAIM FOR REFUND OF STATE HOTEL OCCUPANCY TAX
for federal government entities and state agencies that do not use USAS to reimburse employee travel expenses
- Please type or print.
- Do not write in shaded areas.
- See back of form for instructions.
c. Claimant I.D. number
Maintain complete records in your files to support claims filed.
If documentation is needed, you will be notified.
54100
a. T Code
For comptroller’s use only
d. Agency name
INV
SD
2
3
e. Street address
f. City
g. State
h. ZIP code
A SEPARATE CLAIM FORM MUST BE FILED FOR EACH FISCAL YEAR.
i. Fiscal year
Fiscal quarter
1
ST
quarter
1
2
ND
quarter 2
3
RD
quarter 3
4
TH
quarter 4
TOTAL
1 1 1 1
j.
k.
l.
m.
SEPT-NOV
DEC-FEB
MAR-MAY
JUN-AUG
(Dollars & cents)
Cost of hotel rooms within the city
limits of Galveston, in the indicated
fiscal quarter(s):
$
$
$
$
$
(EXCLUDE TAXES, MEALS AND
.
.
.
.
.
OTHER SERVICES)
1.
2.
3.
4.
5.
Cost of hotel rooms within the city
limits of South Padre Island, in the
indicated fiscal quarter(s):
$
$
$
$
$
(EXCLUDE TAXES, MEALS AND
.
.
.
.
.
OTHER SERVICES)
6.
7.
8.
9.
10.
Cost of hotel rooms within the city
limits of Port Aransas, in the
indicated fiscal quarter(s):
$
$
$
$
$
(EXCLUDE TAXES, MEALS AND
.
.
.
.
.
OTHER SERVICES)
11.
12.
13.
14.
15.
Cost of hotel rooms in all cities, including
Galveston, South Padre Island and Port
Aransas in the indicated fiscal quarter(s):
$
$
$
$
$
(EXCLUDE TAXES, MEALS AND
.
.
.
.
.
OTHER SERVICES)
16.
17.
18.
19
20.
$
Refundable state hotel tax (Multiply Item 20 by .06000): ..........................................................................................
.
21.
n. PM date
1
2
Is this an amended claim for the above fiscal quarter(s)? .........................................................................
YES
NO
o.
I declare the information in this document is true and correct to the best of my knowledge and belief.
Complete this claim form and mail to:
Comptroller of Public Accounts
Name
Title
111 E. 17th Street
Austin, TX 78774-0100
Signature
Date
Phone
For assistance with this claim call (800) 531-5441, extension 3-4545 or (512) 463-4545.
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