Utility Users Tax Exemption Request Form printable pdf download

CITY OF ALAMEDA

UTILITY USERS TAX EXEMPTION REQUEST FORM

Name:

___________________________________________________________________

Address:

___________________________________________________________________

Phone No.:

___________________________________________________________________

Basis for Exemption:

Federal Agency or Subdivision

State Agency or Subdivision

[ ]

Foreign Diplomat

Public School or State College or University

[ ]

Specific municipal code exemption (Specify code section)

[ ]

Other (Please state)

[ ]

Please state:

A. 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.

B. If you are a public agency or subdivision, please state the name of the state or federal department that

you are under:

C. If you are a foreign diplomat, please state your diplomatic title and the name of country you represent:

D. For specific municipal code exemptions and all other exemption requests, attach a copy of supporting

documentation necessary to demonstrate compliance with all relevant exemption requirements.

IMPORTANT: Please attach to this application a copy of a recent utility bill from each utility

provider for which you are requesting an exemption. 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.

Also, please note that this exemption application does not apply to the federal excise tax on

telecommunications. To obtain such an exemption, you must receive a federal exemption certificate

from your telephone provider(s).

DECLARATION

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 : ________________________________________

__________________________

MAIL TO : CITY OF ALAMEDA

ATTN: FINANCE DIRECTOR

2263 SANTA CLARA AVENUE

ALAMEDA, CA 94501

Utility Users Tax Exemption Request Form

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