Application For Utility User'S Tax Exemption Form - City Of Moreno Valley
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1City of Moreno Valley
APPLICATION FOR UTILITY USER’S TAX EXEMPTION
PLEASE PRINT LEGIBLY.
NAME: Last
First
Initial
Social Security No.
Service Address:
ZIP Code:
Number of Adults in Household
Number of children in household and ages
Mobile Park Name (if applicable)
PRINT YOUR ACCOUNT NUMBERS IN THE SPACES BELOW
Southern California Edison
Account Number_________________________________________
Southern California Gas Company
Account Number_________________________________________
GTE or Pacific Bell
Your Phone Number______________________________________
Cell Phone Company Name: _________________
Account Number_________________________________________
TCI Cablevision or Cross Country Wireless Cable
Account Number_________________________________________
Circle One:
E.M.W.D. or
Box Springs Mutual Water Company
Account Number_________________________________________
PROOF OF ANNUAL GROSS INCOME MUST BE PROVIDED – SEE NEXT PAGE OF FORM
CERTIFICATION
I Certify (or declare) under penalty of perjury that:
1. I am a user of the utilities shown heron at premises occupied by myself.
2. The combined gross income of al members of the household in which I reside is less than that specified as 65% of median income
for the County of Riverside as defined annually by HUD.
3. I will notify the City Treasurer within 10 days of any changes which could affect my eligibility for this exemption.
4. I, the undersigned, hereby claim exemption from the utility users tax imposed by Chapter 3.26 of the Moreno Valley Municipal
Code.
NOTE: The exemption will not take effect until this application has been verified and approved by the City of Moreno Valley and
processed by the above utilities. Ordinance #503 amending Title 3 of the City of Moreno Valley Municipal Code, Chapter 3.26,
makes it unlawful for any person to knowingly receive the exemption provided when such a person does not meet the
requirements. Misrepresentation Is deemed a misdemeanor and subject to a fine of $500 and /or imprisonment. The exemption
is not retroactive and any taxes paid prior to the effective date will not be refunded. Exemption is valid only for account numbers
shown above. If you move, a new application must be submitted. Renewal forms must be submitted annually during the month of
February.
DATE: _________________
SIGNATURE:____________________________________________________________________
DO NOT WRITE BELOW THIS LINE
Date
Date Sent to
Exemption
Received_________________
Service Suppliers__________________
Authorized by:_______________________________
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Parent category: Financial