Senior Citizens Utility User'S Tax Exemption Form - City Of Calabasas
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1SENIOR CITIZENS
UTILITY USER=S TAX EXEMPTION
INSTRUCTIONS FOR FILLING OUT FORM ON OTHER SIDE
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PLEASE PRINT ALL INFORMATION LEGIBLY
$
RETURN COMPLETED APPLICATION ALONG WITH A COPY OF YOUR UTILITY BILL(S) TO:
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CITY OF CALABASAS
FINANCE DEPARTMENT
26135 MUREAU ROAD, SUITE 200
CALABASAS, CA 91302-3172
SOCI L S CURITY NUMBER
A
E
-
-
FIRST
INITIAL
LAST
NAME OF
APPLICANT
NUMBER
STREET
APARTMENT/SPACE NUMBER
SERVICE
CITY
ZIP CODE
G
G
SINGLE RESIDENCE
MOBILE HOME
ADDRESS
NUMBER
STREET
APARTMENT/SPACE NUMBER
MAILING
CITY
ZIP CODE
ADDRESS
1) ELECTRIC PROVIDER
ACCOUNT UM ER
N
B
FIRST NAME
INITIAL
LAST
G
G
ARE UTILITIES INCLUDED IN RENT?
YES
NO
2) GAS PROVIDER
ACCOUNT UIM ER
N
B
G
G
ARE UTILITIES INCLUDED IN RENT?
YES
NO
FIRST
INITIAL
LAST
AREA CODE
3) LOCAL EXCHANGE TELEPHONE CO. (e.g. Pacific Bell)
PHONE NUMBER
-
4) OTHER TELEPHONE COMPANIES (e.g., LONG DISTANCE, WIRELESS)
FIRST
INITIAL
LAST
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 Social Security benefits.
NOTE:
(A)
PLEASE NOTIFY THE FINANCE OFFICE OF ANY CHANGE IN THE ABOVE INFORMATION.
(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
SIGNATURE
PHONE NUMBER
DATE
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