Utility Users Tax Remittance Form - City Of El Segundo
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1City of El Segundo
UTILITY USERS TAX REMITTANCE FORM
Name of Utility Service Provider: ________________________________________________
Name of Billing Agent (if any): __________________________________________________
Type of Utility Service(s): ______________________________________________________
(Gas, electricity, water, wired or wireless telephone, VoIP, private communication services, or bundles
thereof)
Company FEIN No.: _________________________________________ Remitted by ACH __________
Tax Period Covered*: _________________________________________
The information that you provide in this remittance form will be maintained as confidential under Rev. and
Tax. Code § 7284.6.
Gross Charges:
$_____________________
Deductions:
$_____________________
[Taxes, Resale sales, Exempt
Accounts]
Non-standard Adjustments**: $_____________________
Net Taxable Charges:
$_____________________
Tax Percentage Applied:
______________%_____
•
Electricity-3%
•
Gas-3%
•
Water-3%
•
Telecom-2%
Penalties:
$_____________________
Interest:
$_____________________
Total Remittance:
$_____________________
Remit to:
ATTN: Finance Department
Make payable to: CITY OF EL SEGUNDO
City of El Segundo
350 Main Street
El Segundo, CA 90245
Please note that payment must be received by the City by no later than the twentieth day of the following
month (due date). Penalties (15%) and interest will be imposed on delinquent payments.
*Please prepare a separate remittance form for each tax period; do not combine tax periods.
**Please describe any non-standard adjustments:
________________________________
______________________________________________________________________________
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