Gross Receipts Tax Fund Assessment Form December 2010

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SOUTH DAKOTA PUBLIC UTILITIES COMMISSION

GROSS RECEIPTS TAX FUND ASSESSMENT

For the Calendar Year ended December 31, 2010

GAS

Name of company and dba

Address of company

Web address of company

Contact name and phone number

Contact person's e-mail address

Tax ID #

FERC

account

Total company

South Dakota

480

Residential sales

481

Commercial and industrial sales $

482

Other sales to public authorities

487

Forfeited discounts

488

Miscellaneous service revenues

489

Transportation revenues

493

Rent from gas property

495

Other gas revenues

TOTAL REVENUES

Signed by company officer:__________________________________

(Type or print name and title)

Subscribed and sworn to before me this ______ day of _____________________ , 20___

____________________________________________

(Notary Public)

(SEAL)

My commission expires: ____________________

49-1-9.1. Providing false or misleading information to commission as misdemeanor. No person may knowingly provide false or misleading information to the commission

in response to, or in compliance with, any statute, order, tariff, rule, direction, demand, or requirement of the commission. A violation of this section is a Class 1 misdemeanor.

Each separate act of providing false or misleading information pursuant to this section constitutes a separate offense. This penalty is in addition to any other authorized

penalties.

For Official Use Only:

Date Received: _________________ Amount: __________________________Check No: ______________________