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CITY OF MODESTO UTILITY USERS TAX REFUND CLAIM PLEASE COMPLETE PARTS 1-4 INSTRUCTIONS ON REVERSE SIDE PART 1 UUTR 11/18/03 LA Last Name First Name Initial Social Security Number Street Address Apt. # Zip Code Phone Number ( ) This claim m PART 2 PART 3 Answer These Questions Annual Gross Household Income A. Have you paid ALL Utility Users Taxes as billed by the utility company? B. Has any other member of your household made application for refund of Utility Users Taxes paid? 1. Salary Per (check one) Month /Year 2. Other Income (Itemized) 3. Total Household Income PART 4 This claim must be filed or postmarked by April 15th and be accompanied by: 1. Complete copy of all utility bills (telephone, gas, electricity and water) 2. Proof that claimant or some member of the household has paid utility taxes. Name of Other Household Members Name Relationship Age Name Relationship Age Amount 4. Utility Users Taxes Paid 5. Refund Claimed (Not to exceed $30.00) Dated day at Modesto, California I certify (or declare) under penalty of perjury that the forgoing is true and correct. $ 0.00 ---PAGE BREAK--- CITY OF MODESTO UTILITY USERS’ TAX REFUND CLAIM TO QUALIFY for a refund, you must be the person whose name appears on the utility bills AND the total gross income of everyone in your household must have been less than $8,700.00 during the last calendar year or income tax year. REFUND ALLOWABLE: Per Modesto Municipal Code 8-2.921, “a refund not to exceed thirty dollars ($30.00) of taxes due and paid under the provisions of this article for utility services rendered in any calendar year... the claim for such refund, for the preceding calendar year, shall be made only during the period of January 1 to April 15 of each year…” YOUR CLAIM is to be filed with the City of Modesto Finance Department, located at 1010 10th Street, Second floor, Suite 2100 or it may be mailed to P.O. Box 642, Modesto, CA 95353, ATTN: Utility Users’ Tax Refund. Please mail your claim starting January 1st BUT no later than April 15th. No claim can be accepted if filed or postmarked later than April 15th. Please answer all questions as accurately as possible, incorrect or incomplete claims will be returned and may delay your refund. PRINT clearly in ink. NAMES OF OTHER HOUSEHOLD MEMBERS: List the name, relationship and age of every person who is or was a member of your household during the last calendar year, January 1 through December 31st. If none, please indicate none. Household members include your spouse (if living with you) and everyone qualified as a dependent for income tax purposes. BE SURE to include the income of all of these household members with your income in Part 3 of the claim form. PART 2: Answer questions A and B. PART 3: HOUSEHOLD INCOME: List all household income received during the last year (Jan 1- Dec 31). Household income is your income and the income of all household members listed in Part 1 of the claim form resulting from salary, wages, tips, fees or charges added together with the net income from all income sources, including but not limited to the following: 1. Alimony 2. Support income 3. Cash public assistance and relief 4. Pensions 5. Annuities 6. Social Security 7. Interest on securities (including tax-free interest on governmental securities) 8. Realized Capitol Gains 9. Worker’s compensation (not including medical benefits) 10. Unemployment insurance 11. Insurance benefits of all kinds (other than medical) 12. Gifts DO NOT include: 1. Medicare benefits 2. Medicaid benefits 3. Gifts of food 4. Gifts between members of the household 5. Receipt of surplus food or other relief as supplied by a Government agency PROOF OF PAYMENT: TOTAL UTILITY USERS’ TAXES PAID MUST BE SUPPORTED BY THE PAID BILLS. PLEASE SEND A COPY OF THE ENTIRE BILL. UTILITY COMPANIES HAVE NO OBLIGATION TO MAKE OR FURNISH, FOR REFUND PURPOSES, PROOF OF UTILITY TAXES DUE OR PAID. Questions regarding your claim? Please call (209) 342-4703 Monday – Friday 8:30 am to 4:30pm.