Utility User'S Tax Exemption - Senior Citizens
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1SENIOR CITIZENS
UTILITY USER'S TAX EXEMPTION
*PLEASE PRINT ALL INFORMATION LEGIBLY
*RETURN COMPLETED APPLICATION ALONG WITH A COPY OF YOUR UTILITY BILL(S) and
PROOF OF RECIEPT OF SSI BENEFITS TO:
CITY OF CALABASAS
M
D
Y
DATE OF BIRTH
FINANCE OFFICE
100 CIVIC CENTER WAY
SOCIAL SECURITY NUMBER
-
-
CALABASAS, CA 91302
FIRST
INITIAL
LAST
NAME OF
APPLICANT
NUMBER
S
T
R
E
E
T
A
P
A
R
T
M
E
N
T
N
U
M
B
E
R
SERVICE
ADDRESS
C
I
T
Y
I Z
P
C
O
D
E
NUMBER
STREET
APARTMENT NUMBER
MAILING
ADDRESS
CITY
ZIP CODE
ELECTRIC PROVIDER
ACCOUNT NUMBER
F
I
R
S
T
I
N
I
T
I
A
L
L
A
S
T
YES
YES
NO
NO
ARE UTILITIES INCLUDED IN RENT?
ARE UTILITIES INCLUDED IN RENT?
GAS PROVIDER
ACCOUNT NUMBER
FIRST
INITIAL
LAST
ARE UTILITIES INCLUDED IN RENT?
YES
NO
-
AREA CODE
LOCAL TELEPHONE CO. (e.g. AT&T)
PHONE NUMBER
FIRST
INITIAL
LAST
OTHER TELEPHONE COMPANIES (e.g., LONG DISTANCE, WIRELESS)
CERTIFICATION
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT:
1) I AM A USER OF THE UTILITIES AT THIS ADDRESS;
2) I AM 62 YEARS OF AGE OR OLDER;
3) I RECEIVE SUPPLEMENTAL SECURITY INCOME (SSI) BENEFITS.
A ) PLEASE NOTIFY THE FINANCE OFFICE OF ANY CHANGE IN THE ABOVE INFORMATION.
NOTE:
B) A NEW APPLICATION MUST BE FILED WITH THE FINANCE OFFICE WITHIN 90 DAYS WHEN THERE
IS A CHANGE OF NAME/ADDRESS IN ORDER TO MAINTAIN ELIGIBILITY OF STATUS.
APPLICANT SIGNATURE
DATE
CITY OF CALABASAS
DATE
CHIEF FINANCIAL OFFICER
APPROVE
DISAPPROVE
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