Form Gao-08 - Assessment Report - Pennsylvania Public Utility Commission - 2008
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1
2COMMONWEALTH OF PENNSYLVANIA
PENNSYLVANIA PUBLIC UTILITY COMMISSION
P.O. BOX 3265
HARRISBURG PENNSYLVANIA 17105-3265
ASSESSMENT REPORT
STATEMENT OF OPERATING REVENUES FOR GENERAL ASSESSMENT
FOR THE CALENDAR YEAR 2008
UTILITY CODE
APPLICATION #
TRADE OR CORPORATE NAME OF UTILITY:
TYPE OF UTILITY SERVICE
CONTACT NAME:
ADDRESS 1:
2008 OPERATION PERIOD
JAN 2008
DEC 2008
FROM
TO
ADDRESS 2 (Floor, Suite, etc.)
CITY, STATE, ZIP:
THIS REPORT MUST BE FILED NOT LATER THAN MARCH 31, 2009.
IF NOT FILED, THE COMMISSION WILL ESTIMATE YOUR INTRASTATE OPERATING REVENUES AND
WILL BASE YOUR ASSESSMENT ON THE ESTIMATED TOTAL. FAILURE TO FILE BY THE MARCH 31
DEADLINE MAY RESULT IN FINES OF UP TO $1,000 FOR EACH DAY OF A VIOLATION (66 Pa. C.S. §3301).
AMOUNT
OPERATING REVENUES FOR CALENDAR YEAR 2008
(Round to the nearest dollar.)
1. TOTAL GROSS OPERATING REVENUES
as shown by books of account
$
and tariffs filed with the Commission.
2. LESS GROSS OPERATING REVENUES
from providing utility service outside
$
of Pennsylvania (Itemize and show computations on side 2)
3. BALANCE: GROSS INTRASTATE REVENUES
on which your assessment
$
will be based (line 1 minus line 2)
NOTARIZATION (Required)
AFFIDAVIT
The information reported is complete, true and correct.
Subscribed and sworn to before me
this_______ day of _____________________2009
(Signature of Individual or Officer)
(Date)
READABLE PRINTED OR TYPED NAME OF SIGNER:
TRADE OR CORPORATE NAME OF UTILITY:
SIGNATURE
OFFICIAL
FEDERAL I.D.
TELEPHONE NO.:
SEAL
(Official Title)
(If different from above)
NEW ADDRESS
(Date Commission Expires)
(FORM GAO-08 SIDE 1)
GAO-08
Page 3 of 4
(OVER)
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