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2. Instructions
   Please complete form and submit payment by the 15th of each month.
4. Name of Property*
5. Contact Person*
7. Address *
8. Email*
10. The Month Fees Were Collected*
11. Number of Rooms Rented *
12. Total Occupancy Fees Collected*
    $2.00 per room
14. Method of Payment*

    1. Pay online (You will be redirected to a secure Wells Fargo payment site once this form is submitted)
    2. Check will be mailed
16. Verification
    I declare and affirm under the penalties of perjury that this claim has been examined by me, and to the best of my knowledge and belief, is in all things true and correct.
18. Signature*
    By typing your name in the field available, you are hereby authorizing the City of Spearfish, South Dakota to accept this as your electronic signature.
Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field