Utility Users Tax Refund Claim Form - City Of San Jose (Page 2 of 3) in pdf

Utility Users Tax Refund Claim Form - City Of San Jose Page 2

SIGNATURE OF CLAIMANT

I declare under penalty of perjury that the foregoing is true and correct. The undersigned is the

taxpayer or the taxpayer’s guardian, conservator, executor or administrator. I am not an agent or

the taxpayer’s attorney. I understand that in order to be eligible for a refund, I must first seek a

refund from the utility company identified above. I certify under penalty of perjury that I have

sought a refund from the utility company identified above and that the utility company has denied

my claim.

________________________________

___________________________________

Signature of Claimant or Representative

Date

________________________________

____________________________________

Print Name

Title/Relationship to Claimant

Check if representative.

(For Finance Department Use Only Below This Line)

( ) Approved

( ) Denied

( ) Returned for insufficiency/timeliness

Reason: ______________________________________________________________________

______________________________________________________________________________

Director of Finance ______________________________ Date ___________________________

T-9137.001/364866_2.doc

Utility Users Tax Refund Claim Form - City Of San Jose Page 2