Utility Users Tax (Uut) Exemption Request - City Of San Jose California

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UTILITY USERS TAX (UUT) EXEMPTION 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 exemption fromUtility 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 Finance, 200 East Santa Clara Street
San Jose, Ca 95113-1905
(For Finance Department Use Only Below This Line)
( ) Approved
( ) Denied
( ) Returned for lack of documentation
Reason: ___________________________________________________________________________
__________________________________________________________________________________
Director of Finance ___________________________________ Date __________________________
200 East Santa Clara Street, San Jose, Ca 95113-1905
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