Federal Exemption Claim Form - County Of Santa Barbara

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County of Santa Barbara
Mailing Address:
Treasurer-Tax Collector
PO Box 579
105 E. Anapamu St # 109
Santa Barbara, CA 93102
Santa Barbara, CA 93101
(805) 568-2927
To _______________________________________________________________________________________
(Name of Hotel)
THIS IS TO CERTIFY that I, the undersigned, am a representative or employee of the Federal Government 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 such Federal Governmental Agency; and that such charges are incurred in the performance
of my official duties as a representative or employee of such Governmental Agency.
Name of Employee: _________________________________________________ ID # ___________________
Name of Agency:
Agency Address:
Dates of Stay:
___________________Through__________________ Rent Paid: $ ___________________
I HEREBY CERTIFY (or declare) under penalty of perjury, that the foregoing statements are true and correct
(Signature of Federal Representative/Employee)
Do not accept this certificate unless the person presenting it shows satisfactory credentials, and meets all the required
conditions. A separate certificate is required for each occupancy, and for each representative. The federal government,
or the federally chartered agency, must either pay you directly, or the employee may pay with a credit card issued by
the federal agency to the employee. Federal employees on vacation are not exempt. The United States Government
and the motel operator have the burden to show that the exemption applies. The completed copies of our Federal
Exemption Claim Form, substantiating all exemptions taken, must be attached to the monthly Transient Occupancy
Return. A hotel employee must validate the Federal Exemption Claim Form by legibly cosigning the form, and listing
their job title.
(Signature of Validating Hotel/Motel Employee)
(Title of Hotel/Motel Employee)


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