Utility Users Tax Remittance Form - City Of Burbank
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1CITY OF BURBANK
UTILITY USERS TAX REMITTANCE FORM
Company Name:
_________________________________________
Company Address:
_________________________________________
_________________________________________
Company Phone No.: _____________________
Company FEIN No.: ___________________
Tax Period Covered : _____________________
Type of Utility Service: ___________________
Please submit separate remittance forms for each category of utility service that you provide, such as, electricity, gas, wireless, and wireline
telecommunications. If more than one category of utility services is bundled together and billed as single amount, then please note above each
category of utility service that is included. The information that you provide in this remittance form will be maintained as confidential under
Rev. and Tax. Code § 7284.6.
Remittance Based Upon Utility Billing
1.
Gross charges (including taxes and surcharges)
$____________________
2.
Deductions
a.
Taxes (federal, state, 911 tax)
$____________________
b.
Sales for Resale
$____________________
c.
Exempt Accounts
$____________________
d.
Other non-taxed charges*
$____________________
3.
Adjustments* (plus or minus)
$____________________
4.
Net taxable charges (line 1 minus lines 2+3)
$____________________
5.
Local Tax Due (@ 7% of line 4)
$____________________
6.
Penalties**
$____________________
7.
Total local tax due (sum lines 5 and 6)
$____________________
*Please attach a description of any adjustments or services not subject to the local tax referred to on lines 2d and 3.
**A 15% penalty shall apply if payment is not received by the City within the first 20 days of the month that follows the
month in which you receive the utility users tax from the customer.
MAKE CHECK PAYABLE TO: CITY OF BURBANK
MAIL TO :
ATTN: DEREK HANWAY, FINANCIAL SERVICES DIR.
CITY OF BURBANK
275 E. OLIVE AVENUE
BURBANK, CA 91502
I declare, under penalty of perjury, that to the best of my knowledge and belief the statements herein, and any
attachments hereto, are true and correct.
Date:
___
Signed:
________________
_______________________________________________________
Phone:
Print Name/Title : ________________________________________
__________________________
Please contact Steve Gibson of Municipal Resource Consultants at (800) 247-4406 if you have any questions regarding
the City boundaries (by street address) or the application of the City’s local tax to the services that you provide your
customers in the City.
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