Exemption Request/ Utility Users Tax - City Of San Jose
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Exemption Request/ Utility Users Tax
Name
Service Address
City of San Jose Finance Department
Utility Company
200 East Santa Clara St
San Jose, California
Customer Utility Account No.
95113-1905
Phone: 408-535-7006
Zip/Postal Code:
Fax: 408-299-6488
STATE AMOUNT AND REASON(S) FOR EXEMPTION REQUEST
(You may use extra sheets if more space is needed. All required documents to be examined as proof of claim
such as a copy of bill or statement must be attached to this request.)
I hereby request exemption from payment of utility users tax payments for the reason(s) indicated above.
I declare under penalty of perjury that the foregoing information and explanation are true and correct.
Executed the
Day of
20
at
, California
Name
Signature of Claimant
Address
Phone Number
Title Of Claimant
(Finance Department Use Only Below This Line)
Approved
Denied
Returned for Lack of Documentation
Reason
Director of Finance
Date
Please mail exemption request to: City of San Jose, Finance Department,200 E. Santa Clara St., 13
Floor, San Jose, CA 95113.
th
Or fax copy to (408)299-6488. Call (408)535-7006 for questions.
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