Fillable Excise Tax Billing MOVE IN APPLICATION City of (City of Carson, California)

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Excise Tax Billing MOVE IN APPLICATION City of (City of Carson, California)

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*Information is required UBA-001This document was produced by the City of Vacaville, Finance Division. – Excise Tax Billing v 06/2019
1
Excise Tax Billing
MOVE IN APPLICATION
Please return completed Application
to:
In Person: Apply Online:
City of Vacaville Complete application online by visiting
Accounts Receivable Division Or www.cityofvacaville.com
650 Merchant St
Vacaville, CA 95688 Email Form to: excisebilling@cityofvacaville.com
Please Print
*Today’s
Date
*
Date
of
Move In
.
*Service
Address
Street Address City State Zip Code
*Name
First Middle Last
*Mailing
Address
Street Address City State Zip Code
* Daytime
Phone
Number
Secondary Phone Number
* Email Address
If none, indicate “N/A”.
* Last
4
digits
of
SSN
(In order to prevent and mitigate ID theft and in compliance with the Fact Act of 2003, it is essential that every written communication, including emails, received by
the Excise Billing Division contains the last four digits of the account holder’s social security number or the tax identification number. In the event that a staff
member within the Excise Billing Division needs to call to obtain additional information, such as the full social security number to validate identity, you must also
provide a daytime telephone number.) *****Applies to all responsible parties******
*Name
First Middle Last
*Mailing
Address
Street Address City State Zip Code
* Daytime
Phone
Number
Secondary Phone Number
* Email Address
If none, indicate “N/A”.
* Last
4
digits
of
SSN
Excise Customer #1
*Tenant Location
Excise Customer #2
*Information is required UBA-001This document was produced by the City of Vacaville, Finance Division. – Excise Tax Billing v 06/2019
2
*Name
First Middle Last
*Mailing
Address
Street Address City State Zip Code
* Daytime
Phone
Number
Secondary Phone Number
* Email Address
If none, indicate “N/A”.
* Last
4
digits
of
SSN
***Additional responsible parties please attach a second application***
Please initial by each line
item.
*Prior Delinquent
Balance(s):
I
acknowledge
that if I have a prior delinquent balance owed to the City of Vacaville, I will have 15 days from
the
date of notification to take care of the balance. If the balance is not taken care of within 15 days from notification, the
collection process will begin.
*Collections
and
Recovery
Costs:
I
acknowledge
that any delinquent balance from my account at this location can be sent to the Franchise
Tax
Board (FTB) for interagency intercept collections' and/or a collection agency. My account would be charged
a
collection recovery fee if it is referred to
collections.
1
FTB operates an intercept program in conjunction with the State
Controller's
Office, collecting delinquent liabilities
individuals
owe to state and local
agencies and
colleges. FTB
intercepts
tax refunds, unclaimed property (UPD) claims and lottery winnings owed to
individuals.
FTB redirects these funds to pay the
individual's
debts
to
the
agencies/colleges
(California Government Code Sections 12419.2, 12419.7, 12419.8, 12419.9, 12419.10,
12419.11
and
12419.12}.
Relationship to Property: Tenant or Apt Manager (circle one)
*Signature______________________________
I certify that this application is complete and accurate
*Date
By signing this form you are giving the Multi-family owned property permission to send this form to the City of Vacaville
For City
of Vacaville Staff Use Only
Received By:
_
Date Entered: _
Entered By:
_
Date
Received:_______
Acknowledgements
Excise Customer #3
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Excise Tax Billing MOVE IN APPLICATION City of (City of Carson, California)

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Completed 28 July 2021

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