Form Ud-16 - Statement Of Gross Earnings And Computation Of Inspection Fee

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FORM UD-16
TENNESSEE REGULATORY AUTHORITY
STATEMENT OF GROSS EARNINGS AND COMPUTATION OF INSPECTION FEE
DUE DATE: April 1, 2013
Company ID #:
Company Name
State the gross receipts from all sources of the utility for the Calendar Year 2012 as provided by Tenn. Code Ann. § 65-4-303:
TENNESSEE
Gross Receipts:
System
Combined
Intrastate
Local Service
$________
$________
$________
Access
________
________
________
Long Distance
________
________
________
Miscellaneous
________
________
________
TOTAL
$
$
$
=======
=======
=======
COMPUTATION OF FEE
1. Tennessee Intrastate Gross Receipts
$____________
2. Less: Exemptions
5,000.00
3. Net Intrastate Gross Receipts (Line 1 - Line 2)
____________
4. 0.425% x First $1,000,000 or line 3, if smaller
____________
5. 0.325% x All over $1,000,000
____________
6. Total Inspection Fee (Line 4 + Line 5) or Minimum Fee of $100
(whichever is greater)
$
I, the undersigned owner, president, or secretary of the above named public utility, doing business in the State 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 TCA § 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 2011, and the inspection fee computed therefrom.
NAME __________________________________
SIGNATURE _________________________
(Please Print)
TITLE __________________________________
TELEPHONE _________________________
Sworn to and subscribed to before me this _____day of ____________, 2013.
Notary Public_____________________________
My Commission Expires:_________________
NOTE: A PENALTY OF 10% PER MONTH OR A FRACTION THEREOF, PURSUANT TO TCA § 65-4-308, WILL BE
st
ASSESSED FOR LATE PAYMENT IF NOT PAID ON OR BEFORE APRIL 1
.
PS0370

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