Utility Users Tax Exemption Request Form For Insurers And Insurance Agents Form California City Of Compton printable pdf download

Utility Users Tax Exemption Request Form For Insurers And Insurance Agents Form California City Of Compton

CITY OF COMPTON

UTILITY USERS TAX EXEMPTION REQUEST FORM

FOR INSURERS AND INSURANCE AGENTS

Company Name:

____________________________________________________________________

Company Address:

____________________________________________________________________

Company Phone No.: ___________________

Type of Business:

License Number:

Status (active or inactive):

Address of each property for which you are requesting an exemption and a description of its use:

NOTE: EXEMPTION REQUESTS APPLY ONLY TO THE ABOVE LISTED ADDRESSES.

Please attach to this application the following information:

A. Insurers: copy of proof of payment of State Gross Premiums Tax

B. Broker-agents: copy of agency appointments or action notices

C. A copy of a recent utility bill from each utility provider for which you are requesting an

exemption. NOTE: Exemptions are valid only for utility services for which a recent bill is

received by the City. If you change utility providers at any time, you must notify the City of the

new utility provider to receive an exemption for the new utility service.

This application for exemption from the City’s Utility Users Tax is valid only for insurers that pay a "Gross

Premiums Tax" under California state law, and broker-agents acting as “agents.” See California Constitution,

Article XIII, Section 28. Note: broker-agents acting as brokers and agents are exempt from paying the Utility

Users Tax as agents, but must pay the tax on the "brokered" portion of their income.

DECLARATION

I declare, under penalty of perjury, that the undersigned company is an insurer or insurance broker-agent,

licensed and in good standing under the laws of the State of California, and that to the best of my

knowledge and belief the statements herein, and any attachments hereto, are true and correct.

Date:

___

Signed:

________________________

_______________________________________________________

Phone:

Print Name/Title : ________________________________________

__________________________

MAIL TO : CITY OF COMPTON

ATTN: FINANCE DIRECTOR

205 SOUTH WILLOWBROOK AVENUE

COMPTON, CA 90220

Utility Users Tax Exemption Request Form For Insurers And Insurance Agents Form California City Of Compton