City Of Modesto Utility Users Tax Refund Claim Form

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City of Modesto
Utility Users Tax Refund Claim
Part I
Last Name
First Name
M.I.
Social Security #
Street Address
Apt #
Zip Code
Phone Number
This claim must be filed before April 15th. It must be accompanied by:
1.
Copy of all utility bills (telephone, gas, electricity and water)
2. Proof that utility taxes have been paid by claimant or some member of the household
Names of Other Household Members
Name
Relationship
Age
Name
Relationship
Age
Part II
Part III
Annual Gross Household Income
Amount
Answer These Questions
1. Salaries & Wages
A. Have you paid ALL Utility Users Taxes as billed by
the utility company?
2. Other Income (Itemize)
Yes
No
B. Has any other member of your household made
application for refund of Utility Users Taxes Paid?
Yes
No
3.
Total Household Income
0.00
4. Utility Users Taxes Paid
5.
Refund Claimed
(not over $30.00)
Dated this
day of
at Modesto, California
(month)
(year)
I certify (or declare) under penalty of perjury that the foregoing is true and correct.
Signed:
1221-01048-112883-002r0129rwpc

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