Emergency Response Fee Statement - City And County Of San Francisco
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1CITY AND COUNTY OF SAN FRANCISCO
OFFICE OF THE TREASURER & TAX COLLECTOR
BUSINESS TAX DIVISION
P.O. Box 7425
San Francisco, CA 94120-7425
Telephone: (415) 554-4400
EMERGENCY RESPONSE FEE STATEMENT
Ownership Name
Business Tax ID No.
DBA
Certificate No.
Care of
Month/Year
Mailing Address
Due Date
City, State, Zip
Delinquent Date
1
TOTAL ACCESS LINES SERVED
2
Less: Number Lines subject to Business and Tax Code section 753(b)
3
Less: Number other exempt Access Lines
4
Total exempt Access lines (Add Lines 2 and 3)
5
Taxable Number of Access Lines (Subtract Line 4 from Line 1)
6
Tax Rate per Access Line
$1.25
7
TOTAL AMOUNT FOR ACCESS LINES (Multiply Line 5 by Line 6)
$
8
TOTAL TRUNK LINES SERVED
9
Less: Number Lines subject to Business and Tax Code section 753(b)
10
Less: Number other exempt Trunk Lines:
11
Total exempt Trunk Lines (Add Lines 9 and 10)
12
Taxable Number of Trunk Lines (Subtract Line 11 from Line 8)
13
Tax Rate per Trunk Line
$9.38
14
TOTAL AMOUNT FOR TRUNK LINES (Multiply Line 12 by Line 13)
$
15
TOTAL HIGH-CAPACITY TRUNK LINES SERVED
16
Less: Number Lines subject to Business and Tax Code section 753(b)
17
Less: Number other exempt Trunk Lines, explain:
18
Total exempt Trunk Lines (Add Lines 16 and 17)
19
Taxable Number of Trunk Lines (Subtract Line 18 from Line 15)
20
Tax Rate per Trunk Line
$168.75
21
TOTAL AMOUNT FOR TRUNK LINES (Multiply Line 19 by Line 20)
$
22
TOTAL DUE (Add Lines 7,14 and 21)
$
23
10% PENALTY, if delinquent (Multiply Line 22 by 10%)
$
24
INTEREST @ 1 % per month, if delinquent (Multiply Line 22 by 1 % per month)
$
25
Adjustments, if any
Explain:
$
26
TOTAL AMOUNT ENCLOSED (Add Lines 22, 23, 24, and 25). Make check payable to the
San Francisco Tax Collector.
$
THIS STATEMENT MUST BE FILED BY THE DUE DATE OR YOU WILL BE SUBJECT TO PENALTIES AND INTEREST.
I declare, under penalty of perjury, under the laws of the State of California, that I have examined this statement and that the
information contained herein is true and complete to the best of my knowledge and belief.
Signature
Date
Print Name:
Title:
Phone:
myh:\911form-final-021201.doc (08/25/03 3:23 PM )
Effective 12/01/2002
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