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CITY OF MODESTO APPLICATION FOR UTILITY USERS TAX REFUND Instructions: In order to qualify for a refund, the applicant must have paid utility user tax in excess of $1,500 on a utility account during a calendar year. The refund period is 12 months in arrears from the receipt of a refund request. Please attach supporting documents (copies of utility bills) to the application. Applicant Name: Service Address: Telephone: Tax Refund Claimed: Please fill out the attached worksheet with billing information and summarize the information below. Attach additional sheets if needed. Utility Account Number Amount Certification: I certify that the information on this application and attachments are true, correct, and complete to the best of my knowledge and belief. I also understand that this application for refund is subject to verification. Company Authorized Signature Print Name Date Title ---PAGE BREAK--- UTILITY USER TAX REFUND COMPANY NAME: SERVICE ADDRESS: SERVICE: SERVICE: ACCOUNT#: ACCOUNT#: YEAR YEAR YEAR YEAR JANUARY JANUARY FEBRUARY FEBRUARY MARCH MARCH APRIL APRIL MAY MAY JUNE JUNE JULY JULY AUGUST AUGUST SEPTEMBER SEPTEMBER OCTOBER OCTOBER NOVEMBER NOVEMBER DECEMBER DECEMBER DATE TOTAL LESS TAX REFUND DATE TOTAL LESS TAX REFUND SERVICE: SERVICE: ACCOUNT#: ACCOUNT#: YEAR YEAR YEAR YEAR JANUARY JANUARY FEBRUARY FEBRUARY MARCH MARCH APRIL APRIL MAY MAY JUNE JUNE JULY JULY AUGUST AUGUST SEPTEMBER SEPTEMBER OCTOBER OCTOBER NOVEMBER NOVEMBER DECEMBER DECEMBER DATE TOTAL LESS TAX REFUND DATE TOTAL LESS TAX REFUND