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Utility Users Tax Exemption Request Form For Federal Credit Unions - City Of El Segundo

CITY OF EL SEGUNDO

UTILITY USERS TAX EXEMPTION REQUEST FORM

FOR FEDERAL CREDIT UNIONS

Company Name:

____________________________________________________________________

Company Address:

____________________________________________________________________

Company Phone No.: ___________________

Charter Type:

Charter 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. Proof of your company's current status as a Federal Credit Union in good standing (e.g., letter of

exemption, or other documentation verifying your company as a current Federal Credit Union).

B. 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 federal credit unions organized

under 12 USC Sec. 1751 et. seq. For other types of exemption requests, please contact the City at the address

indicated below. Please note, credit unions organized under the laws of the State of California are specifically

not exempt from the City’s Utility Users Tax and other taxes. See California Revenue and Tax Code Section

23182 and California Constitution, Article XIII, Section 27.

DECLARATION

I declare, under penalty of perjury, that the undersigned company is a federal credit union, in good

standing, organized under 12 USC Sec. 1751 et. seq., 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 EL SEGUNDO

ATTN: FINANCE DIRECTOR

350 MAIN STREET

EL SEGUNDO, CA 90245

Utility Users Tax Exemption Request Form For Federal Credit Unions - City Of El Segundo