Utility User Tax Exemption Application
(Malibu Municipal Code § 3.28.060)
Applicant’s Name: ______________________________________________________________
(Last) (First) (Middle Initial)
Address: _____________________________________________________________________
(Street) (Apt No) (City) (State) (Zip Code)
Telephone No: _______________________________ Cell No. _____________________
Social Security Number: __ __ __ - __ __ - __ __ __ Date of Birth: __ __ - __ __ - __ __
(MM) (DD) (YY)
Are you a head of household? Yes __________ No __________
Are you 62 years old or older? Yes __________ No __________
Do you receive any supplemental social security benefits? Yes __________ No __________
CERTIFICATION
I certify under penalty of perjury that all information submitted on this application is true to the best
of my knowledge and belief.
_____________________________________________ ________________________
Signature of Applicant Date
……………………………………………………………………………………………………....
Utility Information
Account Name: ________________________________________________________________
Service Address: _______________________________________________________________
Telephone Number: _____________________________________________________________
1. __________________________________ Account Number: _____________________
2. __________________________________ Account Number: _____________________
3. __________________________________ Account Number: _____________________
………………………………………………………………………………………………………
FOR CITY USE ONLY
I hereby certify that the above utility companies are to exempt the listed accounts from the payment
of utility user’s tax within 60 days of receipt of this notice.
Checked: _______________________________ Date: _______________________________
Please contact Lisa Soghor, Assistant City Manager,
with any questions at (310)456-2489 x 224
click to sign
signature
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