Missouri Statement Of Revenue Form - 2008

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STATEMENT OF REVENUE
FY-2010 Mo. PSC Assessment
“Certificated or Registered VoIP” UTILITY COMPANY NAME & ADDRESS
(Please provide the full name of the company as certificated or registered with the Missouri Public Service Commission. Do not abbreviate; yet
include any Commission approved d/b/a or fictitious name, if applicable.)
_____________________________
_____________________________
_____________________________
_____________________________
I, _________________________________, ___________________ _________________
NAME
TITLE
TELEPHONE #
hereby certify that the GROSS INTRASTATE OPERATING REVENUE of the above-
named Company in the State of Missouri, for the calendar year 2008, is:
NOTE: THE GROSS INTRASTATE OPERATING REVENUE REPORTED ON THIS STATEMENT MUST MATCH THE
TOTAL MISSOURI JURISDICTIONAL OPERATING REVENUES REPORTED ON THE COMPANY’S ANNUAL REPORT.
**IF REPORTING ZERO REVENUE, DO YOU WISH TO RETAIN YOUR OPERATING CERTFICATE? _______YES _______NO
ELECTRIC OPERATING REVENUE
$ ______________________
GAS OPERATING REVENUE
$ ______________________
HEATING OPERATING REVENUE
$ ______________________
WATER OPERATING REVENUE
$ ______________________
SEWER OPERATING REVENUE
$ ______________________
TELEPHONE/VoIP OPERATING REVENUE
$ ______________________
TOTAL
$ ______________________
____________________________________
SIGNATURE
State of ___________________)
County of __________________)
Sworn to and subscribed before me a Notary Public in and for said County and State this
_____day of __________________, _______.
DATE
MONTH
YEAR
(SEAL)
__________________________________________
NOTARY PUBLIC
My commission expires ________________________.
Mail one notarized copy of this statement to the Missouri Public Service Commission, Budget & Fiscal
Services Department, P.O. Box 360, Jefferson City, Missouri 65102.
NO LATER THAN MARCH 31, 2009

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