Utility Users Tax (Uut) Refund Claim Form
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1City of Long Beach
RETURN TO:
Utility Users Tax (UUT) Refund Claim Form
City of Long Beach
Attn: City Treasurer
th
333 W. Ocean Blvd., 6
Floor
Business
Residential
Long Beach, CA 90802
Name (please print)
Service Address
Mailing Address
_____________________________________________________________________________
Phone Number
(
)
List the utility companies that you are claiming a Utility User Tax refund (use additional forms if necessary):
Company Name
Company Name
Account Number
Account Number
Company Name
Company Name
Account Number
Account Number
Refunds are eligible from October 1, 2000 through February 28, 2001.
For each month, add the total amount of UUT that you paid to the utility
SAMPLE CALCULATION:
companies listed above and write it below:
October 2000
$
Total
Months
Monthly
Then, a
dd the
November 2000
$
Claimed
UUT Paid
total amount of
UUT paid during
December 2000
$
Oct 2000
$ 4.45
the 5 months and
Nov 2000
$ 3.19
write it below
January 2001
$
Dec 2000
$ 6.89
Jan 2001
$ 5.26
February 2001
$
Feb 2001
$ 3.34
Total
$23.13
Total amount of refund due:
Total amount of refund due:
$ 23.13 x .10 = $ 2.31
.10
x
$
= $
Total amount UUT paid
multiply by .10
Amount of refund due
I understand that any misrepresentation or failure to disclose the correct information on this claim form may result in liability and/or criminal
penalties under the Long Beach Municipal Code.
“This declaration is made under penalty of perjury under the laws of the State of California that the foregoing is true and correct.”
on
at
Signature
Date
City/State
Social Security or Taxpayer ID Number
In order to receive your refund, please complete this form and provide copies of the following documents:
Attach copies of the monthly bills from each utility company and for each month you are claiming a refund. You will qualify for a refund
only if you had an open account between October 1, 2000 through February 28, 2001, and you paid utility users tax. Please contact
your utility company for copies of your bills if you do not have them.
Utility bills must include your name, address, account number, total amount of bill, and amount of utility users tax charged. The refund
payment will be made to the name appearing on the account.
If you need assistance completing this form, please call (562) 570-5700.
For City Use Only
Application reviewed by:
Date:
Please allow up to 12 weeks for refund
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