Utility Users Tax Remittance Form - City Of Modesto
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1CITY OF MODESTO
UTILITY USERS TAX REMITTANCE FORM
Company Name: _____________________________________
Address: __________________________________
City/State/Zip: ____________________________________
Phone No.: ________________________________
FEIN No.: ________________________________________
Tax Period Covered: ________________________
Type of Utility Svc.: ________________________________
Please submit separate remittance forms for each category of utility service that you provide, such as, electricity, gas, wireless,
wireline telecommunications, water and CATV. If more than one category of utility service is bundled together and billed as
single amount, then please note above each category of utility service that is included. The information that you provide in this
remittance form will be maintained as confidential under Rev. and Tax. Code 7284.6.
Remittance Based Upon Utility Billing
1.
Gross charges (including taxes and surcharges)
$_______________________
2.
Deductions
a.
Taxes (federal, state, 911 tax)
$_______________________
b.
Sales for Resale
$_______________________
c.
Exempt Accounts
$_______________________
d.
Other non-taxed charges*
$_______________________
3.
Adjustments* (plus or minus )
$_______________________
4.
Net taxable charges (line 1 minus lines 2+3)
$_______________________
5.
Local Tax Due (@ 6% of line 4)
$_______________________
6.
Penalty**
$_______________________
7.
Total local tax due (sum lines 5 and 6)
$_______________________
*Please attach a description of any adjustments or services not subject to the local tax referred to on lines 2 and 3.
**A 15% penalty shall apply if payment is not received by the City of Modesto before the last day of the month
that follows the month in which you receive the utility users tax from the customer.
MAKE CHECK PAYABLE TO:
CITY OF MODESTO
FINANCE DEPT.
P.O. BOX 642
MODESTO, CA 95353
I declare, under penalty of perjury, 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: ____________________________________
Please Contact Steve Gibson of Municipal Resource Consultants at (800) 247-4406 if you have any questions regarding
the City boundaries (by street address) or the application of the City’s local tax to the services you provide.
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