File # _____________
PLEASE TYPE OR PRINT CLEARLY (Shaded portion is public information)
Street City State Zip Code +4
Address or P.O. Box City State Zip Code +4
Last Name First Name
Street City State Zip Code +4
Business Phone #: Alt Phone #: Fax #:
Contact Person: Title: Phone #:
Ownership Type: Sole Proprietorship Social Security #:
Partnership Corp LLP LLC Trust Fed Emp ID #:
Number of Employees: Date started doing business in Santa Rosa: / /
Standard Industrial Code (SIC): State License # : State Sellers Permit # (if applicable):
Please describe your business activity in detail:
Is business home based? Yes No Does this business involve sale of concealable firearms? Yes No
Is this your first Santa Rosa Business Tax Certificate Application? Yes No
Are all your business activities at this business location under the same ownership? Yes No
Are all your gross receipts being reported under the same federal income tax return? Yes No
Are there multiple business entities at this business location? Yes No
o If yes, please provide additional Federal Employer ID #s on reverse side.
Do you have multiple locations in Santa Rosa? Yes No
o If yes, please list additional Santa Rosa locations on reverse side.
Do you sell anything in Santa Rosa? Yes No (If yes, please be sure to provide State Sellers Permit # above)
What do you sell?
Do you provide services? Yes No If yes, describe:
Web Site Address (posted on City web site for public access):
Email Address (posted on City web site for public access): __________________________________________________
CONFIDENTIAL EMAIL ADDRESS: By providing the following email address, I understand that this address will be used to relay
confidential information pertaining to my Business Tax account, including the renewal information and access code, and that any information
pertaining to my Business Tax account will be available to any person(s) having access to this code .
My CONFIDENTIAL Email address is:__________________________________________________________________
To determine Business Tax Due, use tax calculation table on reverse side. $
(Use total on Line 11 from reverse side)
I declare under penalty of perjury that the information contained in this application is true and correct, and that all required
licenses and permits are in full force and effect.
Signature Title Phone# Date
Santa Rosa business locations require zoning clearance. Contact Community Development, City Hall, Room 3 for this clearance.
Sales or Use Tax may apply to your business activities. Please contact the local State Board of Equalization office for information.
6-04.120 STATEMENTS & RECORDS: City of Santa Rosa Business Tax Ordinance authorizes Representatives of the Collector to
examine, audit and inspect books and records of any taxable business. All persons subject to this provision shall keep complete
records of business transactions and retain them for a period of at least three years.
A Santa Rosa Business Tax Certificate will be issued after completing a review of the information provided on this Business Tax
Application. You may be contacted if we have any questions about your application.
City of Santa Rosa
Business Tax Calculation
.00034 .00084 .00109 .00168
Retail Services Contractor Professionals
Wholesale Property Rental Land Developer Attorney
Manufacturing Public Utilities Recreation and Entertainment Appraiser
Corporate Headquarters Promoter Engineer
2013 2012 2011 2010
1. Gross Receipts*
(You Must Enter Amount in Box)
*DO NOT INCLUDE SALES TAX OR ALCOHOL SALES
(If the amount you entered in the above boxes is less than $25,000, skip lines 2 & 3 and enter $25 in line #4)
2. - $25,000 =
(Subtract Standard Deduction)
3. x Multiplier ** ._ _ _ _ _ =
(Chose multiplier from table above)
4. + $25 =
(Add $25 to figure from line 3)****
****Do not enter less than the Minimum tax of $25 or more than the Maximum tax of $3,000 per year in line #4
If your business opened within the last 30 days skip to line 7.
If your business opened more than 30 days ago, a Penalty of 15% and Interest of .84% (each late month) are due.
Please calculate below.
5. Penalty = 15% X .15 x .15 x .15 x .15
a. Penalty Due =
(Line 4 x Line 5)
a. Enter # of months late = 12 12 12
(Maximum of 12 for each year)
b. Calculate Rate =
(Line 6a x .0084)
c. Interest Due =
(Line 4 x Line 6b & round to cents)
7. Tax Amount Due =
(Add Lines 4, 5a & 6c)
8. State Mandated Disability Access
and Education Revolving Fund Fee ‡ $1.00 N/A N/A N/A
9. Add Lines 7 and 8 from each column above: $
10. A Compliance Review Fee is required for all Santa Rosa based businesses. $25.00
(If business is based inside City limits add this fee. If it is not based inside City limits, please cross out and exclude fee.)
11. Total amount due (Add Line 9 and line 10 if applicable) $
To pay by credit card, provide your account information below:
I authorize the following credit card payment for my City of Santa Rosa Business Tax.
Payment Amount Visa, MasterCard or Discover # Expiration Date
Signature of Cardholder Print Name of Cardholder
‡ On September 19. 2012 Governor Brown signed into law SB-1186 which adds a state fee of $1 on any applicant for a local business license or similar
instrument or permit, or renewal thereof. The purpose is to increase disability access and compliance with construction-related accessibility requirements and
to develop educational resources for businesses in order to facilitate compliance with federal and state disability laws, as specified.
‡ Under federal and state law, compliance with disability access laws is a serious and significant responsibility that applies to all California building owners
and tenants with buildings open to the public. You may obtain information about your legal obligations and how to comply with disability access laws at the
o The Division of the State Architect at www.dgs.ca.gov/dsa/Home.aspx
o The Department of Rehabilitation at www.rehab.cahwnet.gov
o The California Commission on Disability Access at www.ccda.ca.gov
90 Santa Rosa Avenue P.O. Box 1673, Santa Rosa, CA 95402
Phone (707) 543-3170 Fax: (707) 543-3136 Email: firstname.lastname@example.org Web Site: www.srcity.org/bt
Please use this space to provide any additional information or as requested on reverse side.
UTILITY USERS TAX (UUT)
MAXIMUM TAX COLLECTION AMOUNT INFORMATION
The U lity Users Tax that you pay on your electric, gas, telephone (excluding cell phone) and cable television bills is collected by the service providers and
remi ed to the City. In order to prevent overpaying UUT, you may wish to prepay your UUT on any u lity for which you pay more than $20,000 a year for service.
• How much is the U lity Users Tax? • How do I know if I've paid more than the maximum tax?
The tax is 5% of u lity charges. > Ask yourself, "Did I pay more than $1,000 in UUT (or more
than $20,000 in u lity charges) for any one of the taxed
• Is there a limit to how much I have to pay?
u li es (electric, gas, telephone or cable television) in a
The maximum tax is $1,000 for each u lity, for each service
user, at each con guous loca on, per UUT Year.
> Compile your u lity bills for the 12‐month period of Sep‐
• What is the UUT Year? tember 1st through August 31st, separate bills and taxes
The UUT Year is a 12‐month period that begins each paid per u lity, user and con guous loca on and add the
September 1st and runs through August 31st. UUT paid por on from these bills separately. If any one ex‐
ceeds $1,000 you may be en tled to a refund.
Please visit our webpage for more informa on on UUT, maximum tax, process to obtain a refund, or other FAQ’s