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Form Ud-16 - Statement Of Gross Earnings And Computation Of Inspection Fee - Tennessee Regulatory Authority Page 2

FORM UD-16

(Excel Format)

TENNESSEE REGULATORY AUTHORITY

STATEMENT OF GROSS EARNINGS AND COMPUTATION OF INSPECTION FEE

DUE DATE: April 1, 2014

COMPANY ID #:

COMPANY NAME:

State the gross receipts from all sources of the utility for the calendar year 2013 as provided by T.C.A. § 65-4-303:

TENNESSEE

Gross Receipts:

System

Combined

IntraState

Local Service

Access

Long Distance

Miscellaneous

TOTAL

COMPUTATION OF FEE

1. Tennessee Intrastate Gross Receipts

2. Less Exemption

(5,000)

3. Net Intrastate Gross Receipts

(5,000)

4. 0.425% x up to the first $1,000,000

(21)

5. 0.325% x receipts in excess of $1,000,000

6. Computed Fee

(21)

7. INSPECTION FEE DUE (the greater of $100 or the Computed Fee on line 6)

100

I, the undersigned owner, president, or secretary of the above named public utility, doing business in the State of

Tennessee and subject to the control and jurisdiction of the Tennessee Regulatory Authority, for the purpose of paying

the State of Tennessee, as provided by T.C.A. § 65-4-301 et. seq., a fee for the inspection, control, and supervision of the

business, service and rates of said public utility, being first duly sworn, on oath, state that the above figures accurately

state the gross receipts from all sources of the utility for the calendar year 2013, and the inspection fee computed

therefrom.

NAME:

SIGNATURE:

(Please Print)

TITLE:

TELEPHONE:

Sworn to and subscribed to before me this

day of

, 2014

Notary Public:

My Commission Expires:

NOTE:

A PENALTY OF 10% PER MONTH OR FRACTION THEREOF, PURSUANT TO T.C.A. § 65-4-308, WILL BE

ASSESSED FOR LATE PAYMENT IF NOT PAID ON OR BEFORE APRIL 1st.

PS0370

Form Ud-16 - Statement Of Gross Earnings And Computation Of Inspection Fee - Tennessee Regulatory Authority Page 2

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