Utility Users Tax Exemption Request Form - City Of Placentia

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Instructions: After you have downloaded, printed and
CITY OF PLACENTIA
filled out the information requested please sign & date
the completed form and mail (with your documentary
evidence) to: City of Placentia, Finance Department,
UTILITY USERS TAX
401 E. Chapman Avenue, Placentia, CA 92870. Office
EXEMPTION REQUEST
hours are Monday through Fridays - 7:30 a.m. to 5:30
p.m.
: _______________________________________
_________________
APPLICANT
Social Security Number
First Name Initial Last Name
ADDRESS:
_______________________________________
Number Street Apartment City
CERTIFICATION: I CERTIFY, (or declare) under penalty of perjury, that:
1.
I am a user of the utilities shown hereon at premises occupied by myself;
The combined Adjusted Gross Income (as used for purposes of the California Personal Income Tax Law) of all
members of the household in which I reside is less than the sum of $12,500 for the prior calendar year; and
I have enclosed documentary evidence (copy of State or Federal Income Tax Return; Social Security Benefit
Statement; etc.) or other applicable proof of income.
__________________
______________________________
Date
Signature of Applicant
UTILITY COMPANY INFORMATION
Fill in the account number for the utility companies from which you receive service.
__ __ __ __ - __ __ __ __ __ __ - __ __ __
Cable Company
__ - __ __ - __ __ __ - __ __ __ __
So. California Edison Co.
__ __ __ - __ __ __ - __ __ __ __ - __
So. California Gas Co.
__ __ __ - __ __ __ - __ __ __ __
Pacific Bell
FINANCE DEPARTMENT USE ONLY
Eligible:
Yes
No
APPROVED:
___
___
Utility
companies
____________
notified:
Date
______________
Director of Finance

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