Name of Utility Service Provider*

Name of Billing Agent (if any)

Type of Utility Service(gas, electricity, video, wired or wireless telephone, private communications services, or bundled thereof)*

Company FEIN number*

Remitted by ACH*

Yes

No

Tax Period Covered (please prepare a separate remittance form for each tax period; do not combine tax periods)*

The information that you provide in this remittance form will be maintained as confidential under Revenue and Tax Code Section 7284.6

Gross Charges*

Deductions (Taxes, Resale Sales, Exempt Accounts)

Non-Standard Adjustments**

Net Taxable Charges*

Tax at 5.5% *

Penalties (15%)

Interest

Total Remittance*

Remit to:
City of Emeryville
Attn: Finance Department
1333 Park Avenue
Emeryville, CA 94608

Please note that payment must be received by the City no later than the twentieth day of the following month (due date) and interest will be imposed on delinquent payments.

** Describe any Non-Standard Adjustments

Prepared by (name and title)*