Print Form
SOUTH DAKOTA PUBLIC UTILITIES COMMISSION
GROSS RECEIPTS TAX FUND ASSESSMENT
For the Calendar Year ended December 31, 2009
ELECTRIC
Name of company and dba
Address of company
Contact name and phone number
Contact person's e-mail address
Web address of company
Tax ID #
-
FERC
Total company
account
South Dakota
440
Residential sales
$
Commercial and industrial sales
442
$
444
Public street and highway lighting
$
445
Other sales to public authorities
$
446
Sales to railroads and railways
$
450
Forfeited discounts
$
$
451
Miscellaneous service
454
Rent from electric property
$
456
Other electric revenues
$
TOTAL REVENUES
$
Signed by company officer: ____________________________________
(Type or print name and title)
, 20
day of
.
Subscribed and sworn to before me this
___
________________________
______
____________________________________
(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: ______________________