Form Rct-126 - Membership Report For Use By Electric Co-Operative Corporations - 2011 Page 2
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1
2RCT-126 (I)
Page 2
1260011201
Address of the corporation’s principal office is
(
)
STREET ADDRESS
(CITY)
(STATE)
(ZIP CODE)
Did the corporation provide retail electric services outside its certified territory during the tax period covered
o
o
by this report?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If yes, the co-op must also file the Gross Receipts Tax Report for Electric, Hydroelectric and Water Power
Companies, RCT-112.
OFFICERS OF THE CORPORATION
NAME
TITLE
HOME STREET ADDRESS
CITY
STATE
ZIP CODE
NAME
TITLE
HOME STREET ADDRESS
CITY
STATE
ZIP CODE
NAME
TITLE
HOME STREET ADDRESS
CITY
STATE
ZIP CODE
NAME
TITLE
HOME STREET ADDRESS
CITY
STATE
ZIP CODE
NAME
TITLE
HOME STREET ADDRESS
CITY
STATE
ZIP CODE
On Dec. 31, 2011
Total number of members in the corporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fee of $10 per 100 members or fraction thereof. Enter this amount on Page 1, Column A. . . . . . . . . . . . . . . . . . . . . . . . . .
$
(whole dollars only)
1260011201
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