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Form Rct-126 - Membership Report For Use By Electric Co-Operative Corporations 2006 Report

RCT-126 (12-06)

(Department Use Only)

1 1 1 1 2 2 2 2 6 6 6 6 0 0 0 0 0 0 0 0 0 0 0 0 6 6 6 6 1 1 1 1 0 0 0 0 1 1 1 1 7 7 7 7

DLN

ACCOUNT ID

(CORPORATE BOX NUMBER)

Commonwealth of Pennsylvania

MEMBERSHIP REPORT

(Department Use Only)

PA DEPARTMENT OF REVENUE

FOR USE BY

Date Received

PO BOX 280407

ELECTRIC CO-OPERATIVE CORPORATIONS

HARRISBURG, PA 17128-0407

2006 REPORT

FEDERAL ID (EIN)

NAME

MAKE ADDRESS CHANGES IN SPACE BELOW

ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

First Report

Amended Report (See Instructions)

Last Report (out-of existence as of _________________________________ )

ANNUAL PAYMENTS

TAX PERIOD ENDING

DUE DATE

12-31-06

07-01-07

✔

Fill in corresponding self-assessed tax, remittance amount and Grand Totals.

REVENUE USE ONLY

B. Estimated

A. Tax Liability

C. Restricted

Remittance

Payments & Credits

✔

T/C 01-15 TAX TYPE

from Tax Report

Credit

A minus B minus C

TYPE

BUDGET

on Deposit

CODE

✔

Electric Co-Operative Corporation

127164

GRAND TOTALS

PLEASE CHECK THIS BLOCK ONLY IF THE TOTAL PAYMENT SHOWN ABOVE HAS BEEN (OR WILL BE) PAID BY ELECTRONIC FUNDS TRANSFER (EFT).

OVERPAYMENT INSTRUCTIONS

(CHECK ONLY ONE BOX)

Automatically transfer overpayments to other current tax period underpaid taxes and the remaining portion of the overpayment(s) to the next tax period.

Automatically transfer $

of the current tax period overpayment(s) to the next tax period after paying any other current tax period

underpaid taxes and refund the remaining portion of the current tax period overpayment(s).

Refund the overpayment(s) of the current tax period after paying any other current tax period underpaid taxes.

I hereby affirm under penalties prescribed by law that this report (including any accompanying schedules and statements) has been examined by me and to the best of my knowledge and belief is a true,

correct and complete report. If prepared by a person other than the taxpayer, his declaration is based on all information of which he has any knowledge.

Signature of Officer of Company

Title

Date

Telephone Number

(

)

PRINT Individual Preparer or Firm’s Name

Signature of Preparer

PRINT Individual or Firm’s Street Address

Title

Telephone Number

(