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Report Of Gross Operating Revenues Derived From Intra-Kentucky Business - Kentucky Public Service Commission

Rev. 7/19/2004

KENTUCKY PUBLIC SERVICE COMMISSION

REPORT OF GROSS OPERATING REVENUES DERIVED FROM INTRA-KENTUCKY

BUSINESS FOR THE YEAR ENDING DECEMBER 31, 20______

____________________________________________________________________________________________

(Utility Reporting)

(Address)

FEIN # (Federal Employer Identification Number)

(DO NOT INCLUDE TAXES COLLECTED)

(1) Gross Revenues of Electric Utility…………………………….$_______________________

(2) Gross Revenues of Gas Utility…………………………………$_______________________

(3) Gross Revenues of Water Utility……………………………….$_______________________

(4) Gross Revenues of Sewer Utility……………………………….$_______________________

(5) Other Operating Revenues……………………………………..$_______________________

*** TOTAL GROSS REVENUES…………………..…..$_______________________

OATH

State of…………………………….)

) ss.

County of………………………….)

_________________________________________________being duly sworn, states that he/she is

(Officer)

______________________________of the _______________________________________________ that the above

( Official Title)

(Utility Reporting)

report of gross revenues is in exact accordance with ______________________________________, and that such

(Utility Reporting)

books accurately show the gross revenues of: _________________________________________, derived from

(Utility Reporting)

Intra-Kentucky business for the calendar year ending December 31, 20_________.

________________________________________________________

(Officer)

(Title)

This the ________________________ day of ___________________________________________, 20__________

_____________________________________________________________________________________________

(Notary Public)

(County)

(Commission Expires)

NOTE: ANY DIFFERENCE BETWEEN THE AMOUNT OF THE GROSS REVENUES SHOWN IN THE

ANNUAL REPORT AND THE AMOUNT APPEARING ON THIS STATEMENT MUST BE

RECONCILED ON THE REVERSE OF THIS REPORT.

Report Of Gross Operating Revenues Derived From Intra-Kentucky Business - Kentucky Public Service Commission