Form Gao-09 - Assessment Report - Pennsylvania Public Utility Commission Page 4
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5PA PUC GAO-09
COMMONWEALTH OF PENNSYLVANIA
PENNSYLVANIA PUBLIC UTILITY COMMISSION
P.O. BOX 3265
HARRISBURG PENNSYLVANIA 17105-3265
ASSESSMENT REPORT
STATEMENT OF 2009 CALENDAR YEAR GROSS INTRASTATE (JURISDICTIONAL) OPERATING REVENUES TO
CALCULATE THE GENERAL REGULATORY ASSESSMENT
FOR FISCAL YEAR 2010-2011
SECTION 1
TRADE OR CORPORATE NAME OF UTILITY:
UTILITY CODE:
APPLICATION No:
CONTACT NAME:
TYPE OF UTILITY SERVICE
ADDRESS I:
2009 OPERATION PERIOD
JAN 1,2009
DEC 31,2009
through
FROM
ADDRESS 2 (Floor, Suite, etc.)
CITY. STATE. ZIP:
SECTION 2
This Report MUST BE FILED not later than MARCH 31, 2010. Failure to file by the March 31, 2010 deadline may result in fines
up to $1,000 for each day a violation continues (66 Pa. C.S. § 3301).
OPERATING REVENUES FOR CALENDAR YEAR 2009
AMOUNT
(Round to the nearest dollar.)
2009 INTRASTATE (JURISDICTIONAL) OPERATING REVENUES: (Please see instructions
$
for details on where in your annual report this number is found.)
SECTION 3
AFFIDAVIT
I affirm that the information reported herein is complete, true and correct.
__________________________________
_______________
of Individual or Officer)
(Date)
(Signature
NOTARIZATION
(Required)
READABLE (PRINT OR TYPE) NAME OF INDIVIDUAL or OFFICER ABOVE:
Subscribed and sworn to before me
this_______ day of _________________2010
TRADE NAME OR CORPORATE NAME OF UTILITY:
NOTARY SIGNATURE
OFFICIAL
SEAL
(Official Title)
FEDERAL ID:
TELEPHONE NO.:
Office (
)
Ext.
Cell
(
)
Name of person to be contacted for additional information:
(Date My Commission Expires)
Name:_____________________________________________________________
(printed)
Telephone:
Ext.
GAO-09
Page 3 of 4
(OVER)
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