Form Prc/asd -001 - Carrier And Utility Inspection Report Form
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1CARRIER AND UTILITY INSPECTION REPORT
Remit report and payment to:
Public Regulation Commission
ASD – Carrier and Utility Inspection Fees
P. O. Drawer 1269
Santa Fe, NM 87504
__________________________________________________________________________________________
Pursuant to Section 63-7-20 NMSA, 1978, each utility and carrier doing business in this state which is subject to the control and
jurisdiction of the commission by virtue of the provisions of Article 11 of the Constitution of the State of New Mexico, with respect to
its rates and service shall pay annually to the commission a fee in performance of its duties as now provided by law.
____________________________________________________________________________________________________________
Business Information
Part I
Legal Name:
________________________________ Contact Person: _________________________
DBA:
________________________________Title:
_____________________________
Address:
________________________________Phone:
(
)_________________________
City, State, ZIP
________________________________
FEIN (10 digits):
_____-__________________
Fees for the calendar year ended December 31, 2001
Part II
A.
Total Gross Receipts from all business
$_____________________________________
B.
Less: Interstate Receipts
______________________________________
C.
Total Intrastate Receipts
______________________________________
D.
Total Amount Payable (C. times .005)
______________________________________
Part III
Method of Payment
A.
Total Payment Enclosed
(
) or
B.
Four Equal Installments
(
)
(Due January 20, 2002)
a.
January– March ( ) Due January 20, 2002
b.
April-June
( ) Due April 20, 2002
c.
July-September (
) Due July 20, 2002
2002
d.
October-Dec.
(
) Due October 20,
Statement
Part IV
State of____________________________)
)
ss
County of__________________________)
I,_________________________________, being ___________________________ of the above named company, whose
return of the Carrier and Utility Report is included herein, do solemnly swear that the above information is complete, true
and correct to the best of my knowledge.
___________________________________
Signature
Subscribed and sworn to me this __________ day of January 2002.
_____________________________
My Commission Expires:___________________
Notary Public
Form PRC/ASD –001 Rev Jan 2002
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