Form Ud-16 - Statement Of Gross Earnings And Computation Of Inspection Fee - Tennessee Regulatory Authority
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1
2FORM UD-16
Market Regulated
(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 REVENUES
Total
Market
Non-Market
Gross Receipts:
Company
Total
Regulated
Regulated
Local Service
Access
Long Distance
Miscellaneous
TOTAL
$
-
$
-
$
-
$
-
COMPUTATION OF FEE
1. Tennessee Intrastate Non-Market Regulated Gross Receipts in excess of $5,000
$
(5,000)
2. 0.425% x up to the first $1,000,000
$
(21)
3. 0.325% x receipts in excess of $1,000,000
$
-
4. Computed Fee on Non-Market Regulated Revenues (Minimum Due = $100)
$
(21)
5. INSPECTION FEE DUE (See Note on Line 6)
$
-
6.
The greater of the Computed Fee on line 4 above or the fee shown on Line 7
7. MINIMUM FEE DUE: 49% of the Fee computed on April 1, 2012, Return
49%
$
-
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
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