Senior Citizen Utility Tax Exemption Application


Seniors in the Cupertino city limits age 65 or older are exempt from the tax on their gas, electric and phone bills only. There is no exemption available for cable television service. To file for an exemption, please complete this form. Renewals are not necessary unless you change your local or long distance phone company.


Name  
Address  
Date of Birth (mm/dd/yyyy)
Phone Number  
Email

Name as shown on your PG&E bill  
PG&E Account No  

Local phone service company.
  Please choose one of the following:

  Account Number
 
  Name as shown on your Phone bill  

Long distance company.

  Please choose one of the following:

Cell phone company.

  Please choose one of the following:



UNDER PENALTY OF PERJURY I DECLARE THAT I AM THE RESIDENT AND THE INFORMATION LISTED ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.