Utility Users Tax(Uut) Refund Request - City Of San Jose California
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UTILITY USERS TAX(UUT) REFUND REQUEST
NAME ____________________________________________________________________________
(Service User Name)
ADDRESS _________________________________________________________________________
(Where service is provided)
NAME OF UTILITY COMPANY ____________________________________________________
(Service Provider)
CUSTOMER ACCOUNT NUMBER
_________________________________________________
(As it appears on bill/statement)
STATE AMOUNT AND REASON(S) FOR REFUND 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 a refund of previous 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 ______________________________
_________________________________
ADDRESS____________________________
(Signature of Claimant)
____________________________
PHONE ______________________________
_________________________________
(Title of Claimant)
Please mail exemption request to: City of San Jose, Treasury Division, 801 North First Street, Room
217, San Jose, CA 95110. Or fax copy to (408) 277-3720. Call (408) 277-5051 for questions.
(For Finance Department Use Only Below This Line)
( ) Approved
( ) Denied
( ) Returned for lack of documentation
Reason: ___________________________________________________________________________
__________________________________________________________________________________
Director of Finance ___________________________________ Date __________________________
801 N. First St. Room 217 San José, CA 95110 tel (408) 277-4184 fax (408) 277-3720
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