Louisiana Public Service Commission
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LOUISIANA PUBLIC SERVICE COMMISSION ______
ANNUAL REPORT
OF
OPERATIONS
BY
WASTEWATER PUBLIC UTILITIES
EXACT LEGAL NAME OF COMPANY
Month / Day / Year (END DATE REPORTED PERIOD)
The filing of the Annual Report and/or related correspondence should be directed to the:
Louisiana Public Service Commission ATTN: Utilities Division – Annual Report 602 North 5th Street, 12th Floor Baton Rouge, Louisiana 70821
LOUISIANA, WITHIN ONE HUNDRED TWENTY DAYS (120) AFTER CLOSE OF REPORTED PERIOD. COMPANY IDENTIFICATION AND INSTRUCTION
COMPANY DATA: NAME: ______ADDRESS: ______LOCATION: ______
OWNER (S): NAME: ______ADDRESS: ______PHONE NUMBER: ______
PRESIDENT: NAME: ______ADDRESS: ______PHONE NUMBER: ______
ANNUAL REPORT: 1. TO WHOM TO BE SENT: ______2. WHO FILLED OUT THIS REPORT: ______INSTRUCTIONS
PAGE FOUR THROUGH PAGE EIGHT REPORTS FINANCIAL DATA PERTINENT TO YOUR COMPANY. IF YOU HAVE FINANCIAL STATEMENTS FOR YOUR SYSTEM (BALANCE SHEET AND INCOME STATEMENT) OR CURRENT YEARS INCOME TAX FILINGS, THESE MAY BE SUBSTITUTED INTO THE REPORT BOOKLET TO PROVIDE FINANCIAL DATA INSTEAD OF COMPLETING PAGE FOUR THROUGH PAGE EIGHT.
ON PAGE TWO OF THIS REPORT, SHOW COST OF THE PLANT ITEMS IN DOLLARS, NOT IN NUMBER OF UNITS SUCH AS FOOTAGES FOR MAINS. PAGE THREE SHOWING ACCUMULATED DEPRECIATION OF PLANT SHOULD ALSO BE SHOWN IN DOLLARS– NOT UNITS.
IF YOUR FINANCIAL STATEMENTS ARE INCORPORATED INTO THE REPORT, IN LIEU OF INDICATING THE NUMBER OF CUSTOMERS SERVED IN THE SPACE ON PAGE FOUR, PLEASE SHOW THE NUMBER OF CUSTOMERS SERVED IN THE SPACE BELOW:
VII. NUMBER OF CUSTOMERS/CONNECTIONS BY CLASSIFICATION RESIDENTIAL COMMERICAL INDUSTRIAL OTHER/GOV’T TOTAL
1 SEWERAGE PLANT ITEM BALANCE ADDITIONS RETIREMENTS ABANDONED OR BALANCE BEGINNING OF DURING YEAR DURING YEAR REMOVED FROM END OF YEAR SERVICE YEAR
(A) (B) (C) (D) (E) (F)
MAINS $ $ $ $ $
SERVICES
OXIDATION PONDS
TREATMENT PLANTS
OTHER
TOTAL
MATERIALS & SUPPLIES (ON HAND) ______CONTRIBUTIONS FROM CUSTOMERS FOR CONSTRUCTION ______ADVANCES FROM CUSTOMERS FOR CONSTRUCTION ______CONSTRUCTION WORK IN PROGRESS (END OF YEAR) ______
2 ACCUMULATED RESERVE FOR DEPRECIATION; DEPLETION AND AMORTIZATION
ITEM SERVICE LIFE BALANCE ADDED CHARGES BALANCE (YEARS) BEGINNING OF DURING YEAR DURING YEAR END OF YEAR (CREDIT) (DEBIT) YEAR
(A) (B) (C) (D) (E) (F)
MAINS $ $ $ $ $
SERVICES
OXIDATION PONDS
TREATMENT PLANTS
OTHER
TOTAL
3 OPERATING REVENUES
NO. CUST. $ SEWERAGE COLLECTION CHARGES
______
______
OTHER SEWERAGE REVENUE
FORFEITED DISCOUNTS $______CONNECTION FEES
______MISC. OPERATING REVENUE
______TOTAL OTHER SEWERAGE REVENUE
______
TOTAL OPERATING REVENUE $______
OTHER INCOME
INTEREST $______RENT
______MISC. OTHER INCOME ______TOTAL OTHER INCOME ______
TOTAL INCOME $______
MEANS OF DISPOSAL (OXIDATION PONDS, TREATMENT PLANTS, OTHER)______
4 OPERATING EXPENSES THE OPERATING EXPENSES OF THE RESPONDENT AS CARRIED ON ITS BOOKS SHOULD BE SHOWN ON THE FOLLOWING PAGES.
ACCOUNT NAME $
TREATMENT EXPENSES: OPERATION SUPERVISION & ENGINEERING______PURIFICATION LABOR______SUPPLIES & ______EXPENSES______MAINTENANCE SUPERVISION & ENGINEERING______MAINTENANCE OF STRUCTURES & IMPROVEMENTS______MAINTENANCE OF TREATMENT EQUIPMENT______RENTS______TOTAL TREATMENT EXPENSES______COLLECTION & TRANSMISSION EXPENSES: ______OPERATION SUPERVISION & ENGINEERING______DEPARTMENTAL OFFICE EXPENSES______SERVICES ON CUSTOMERS’ PREMISES______MAINTENANCE SUPERVISION & ENGINEERING______MAINTENANCE OF STRUCTURE & IMPROVEMENTS______MAINTENANCE OF MAINS______MAINTENANCE OF OTHER COLLECTION PLANT______RENTS______OTHER______TOTAL COLLECTION & TRANSMISSION EXPENSES ______CUSTOMERS’ ACCOUNTING & COLLECTION EXPENSES: ______SUPERVISION______CUSTOMERS’ BILLING & ACCOUNTING______MISCELLANEOUS ACCOUNTING & COLLECTING EXPENSES______UNCOLLECTIBLE ACCOUNTS______RENTS______TOTAL CUSTOMERS ACCOUNTING & COLLECTING EXPENSES ______5 OPERATING EXPENSES - CONTINUED
ACCOUNT NAME $
ADMINISTRATIVE & GENERAL EXPENSES:
SALARIES OF GENERAL OFFICES & EXECUTIVES______OTHER GENERAL OFFICE SALARIES______EXPENSES OF GENERAL OFFICERS & GENERAL OFFICE EMPLOYEES______GENERAL OFFICES SUPPLIES & EXPENSES______MANAGEMENT & SUPERVISION FEES & EXPENSES______SPECIAL SERVICES______LEGAL SERVICES______REGULATORY COMMISSION EXPENSES (INCLUDING SUPERVISION & INSPECTION FEE)______INSURANCE______INJURIES AND DAMAGE______EMPLOYEES’ WELFARE EXPENSES & PENSIONS______MISCELLANEOUS GENERAL EXPENSES______MAINTENANCE OF GENERAL PROPERTY______RENTS______ADMINISTRATIVE & GENERAL EXP. TRANSFERRED-CR.______TOTAL ADMINISTRATIVE & GENERAL EXPENSES______
______TOTAL OPERATING EXPENSES: 6 DEPRECIATION EXPENSES: (COL. D-P.3) $ ______
TAXES: (OTHER THAN INCOME) – GIVE NAME & AMOUNT OF EACH TAX CLAIMED APPLICABLE TO THIS OPERATION ONLY.
PROPERTY ______FRANCHISE ______GROSS RECEIPTS ______PAYROLL ______OTHER ______
TOTAL $______
INCOME TAXES: FEDERAL ______STATE ______
TOTAL $______
7 OTHER INCOME DEDUCTIONS:
INTEREST EXPENSE $______RENT EXPENSE ON NON-UTILITY PROPERTY ______MISCELLANEOUS OTHER INCOME DEDUCTIONS ______TOTAL OTHER INCOME DEDUCTIONS $______
PREPAYMENTS:
INSURANCE $______OTHER ______
TOTAL PREPAYMENTS $______
8 AFFIDAVIT
State of ______
County/Parish of ______
I,______, ______for ______(Name of Affiant) (Title of Affiant) (Title or Name of Respondent) attest that it is my duty to have supervision over the books of account of the respondent and to control the manner in which such books are kept. I know that such books have, during the period covered by the foregoing report, been kept in good faith. I carefully examined the said report and to the best of my knowledge and belief the entries contained in the said report have, so far as they related to matters of account, been accurately taken from the said books of account and are in exact accordance therewith. I believe that all other statements of fact contained in the said report are true; and that the said report is a correct and complete statement of the business and affairs of the above named respondents during the period of time.
______(Signature of Affiant)
Subscribed and sworn to before me a Notary Public, in and for the State and County/Parish above named, this ______, day of ______, 20_____.
My commission expires______
______(Signature of Notary Public)