Annual Application For Utility Users Tax Exemption - City Of Moreno Valley - 2014
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1
2City of Moreno Valley
Annual Application for
2014 Utility Users Tax Exemption
Please print clearly (por favor de imprimir con claridad)
Name: Last
First
M.I.
Service Address:
Zip Code:
Number of Adults
Number of Children
Mobile Park Name
in Household:
in household and ages:
(if applicable):
PRINT YOUR UTILITY PROVIDER NAME AND ACCOUNT NUMBERS IN THE SPACES BELOW
Electricity Provider
Name: ________________________________ Acct: __________________
The Gas Company
Name: ________________________________ Acct: __________________
Telephone Company
Name: ________________________________ Acct: __________________
Cell Phone Company
Name: ________________________________ Acct: __________________
Cable TV
Name: ________________________________ Acct: __________________
Name: ________________________________ Acct: __________________
Water Company
PROOF OF ANNUAL GROSS INCOME MUST BE PROVIDED - SEE BACK OF FORM CERTIFICATION
I Certify (or declare) under penalty of perjury, that:
1.
I am a user of the utilities shown hereon at premises occupied by myself.
2.
The combined gross income of all members of the household in which I reside is less than that
specified as 65% of median household income for the County of Riverside as defined annually by
HUD.
3.
I will notify the City Treasurer within 10 days of any changes, which could affect my eligibility for this
exemption.
4.
I, the undersigned, hereby claim exemption from the utility users tax imposed by Chapter 3.26 of the
Moreno Valley Municipal Code.
Note: The exemption will not take effect until this application has been verified and approved by the City of Moreno Valley and
processed by the above Utilities. Ordinance #503 amending Title 3 of the City of Moreno Valley Municipal Code, chapter 3.26
makes it unlawful for any person to knowingly receive the exemption provided when such person does not meet the requirements.
Misrepresentation is deemed a misdemeanor and subject to a fine of $500 and/or imprisonment. The exemption is not retroactive
and any taxes paid prior to the effective date will not be refunded. Exemption is valid only for account numbers shown above. If
you move, a new application must be submitted. Renewal forms with proof of gross income must be submitted annually during
the month of February.
Signature
DO NOT WRITE BELOW THIS LINE
Date Received: _______________________ Date Sent to Service Providers: _________________ Exemption Authorized by: _____________
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