Form Rct-126 - Membership Report Electric Cooperative Corporations Page 2

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1260012205

Revenue ID

RCT-126

(09-14)

PAGE 2 OF 2

CALCULATION OF TAX

Street Address of Corporation’s Principal Office

City

State

ZIP

Did the corporation provide retail electric services outside its certified territory during

Y/N

the tax period covered by this report?

If yes, the co-op must also file the Gross Receipts Tax Report for Electric, Hydro-Electric and Water Power Companies,

RCT-112.

Total number of members in the corporation

Fee of $10 per 100 members or fraction thereof. Enter amount on Page 1, Line 1.

1260012205

Preparer’s Information:

Firm Name

Individual Preparer Name

Firm FEIN

Phone

Address

City

Social Security Number

or PTIN

State

ZIP

I affirm under penalties prescribed by law this report, including any accompanying schedules and statements, has been prepared by me and to the best of my

knowledge and belief is a true, correct and complete report.

Signature of Preparer

Date

Signature of Preparer – Please sign after printing

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RETURN TO PAGE 1

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