Arizona Annual Report – Fill Out and Use This PDF

ARIZONA CORPORATION COMMISSION

UTILITIES DIVISION

ANNUAL REPORT MAILING LABEL – MAKE CHANGES AS NECESSARY

Please click here if pre-printed Company name on this form is not your current Company name or dba name is not included.

Please list current Company name including dba here:

__________________________________________________________________________

ANNUAL REPORT

FOR YEAR ENDING

FOR COMMISSION USE

COMPANY INFORMATION

Company Name (Business Name) _________________________________________________________

Mailing Address ____________________________________________________________________________

(Street)

_________________________________________________________________________________________

(City)(State)(Zip)

__________________________________________________________________________________________

Telephone No. (Include Area Code)Fax No. (Include Area Code)Cell No. (Include Area Code)

Email Address______________________________________________________________________________

Local Office Mailing Address _______________________________________________________________

(Street)

__________________________________________________________________________________________

(City)(State)(Zip)

__________________________________________________________1-800-___________________________

Customer Service Phone No. (Include Area Code)

Website address ___________________________________________________________________________

MANAGEMENT INFORMATION

Management Contact:_________________________________________________________________________________

(Name)(Title)

_______________________________________________________________________________________________________________________

Email Address______________________________________________________________________________

Regulatory Contact:___________________________________________________________________

(Name)

Email Address______________________________________________________________________________

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Statutory Agent:__________________________________________________________________________

(Name)

________________________________________________________________________________________________________________________

(Street)(City)(State)(Zip)

____________________________________________________________________________________________________________

Telephone No. (Include Area Code)Fax No. (Include Area CodeCell No. (Include Area Code)

Attorney:________________________________________________________________________________

_______________________________________________________________________________________________________________________

Telephone No. (Include Area Code)Fax No. (Include Area Code)Cell No. (Include Area Code)

Email Address:_____________________________________________________________________________

Important Changes During the Year

If yes, please provide specific details in the box below.

If yes, please provide specific details in the box below.

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OWNERSHIP INFORMATION

Other (Describe)______________________________________________________________________

COUNTIES SERVED

Check the box below for the counties in which you are certificated to provide service:

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SERVICES AUTHORIZED TO PROVIDE

Check the following box(es) for the services that you are authorized to provide:

Resold Long Distance/Interexchange Telecommunications Services (RLD) Resold Local Exchange Telecommunications Services (RLEC)

Facilities-Based Long Distance/Interexchange Telecommunications Services (IXC) Facilities Based Local Exchange Telecommunications Services (CLEC)

Facilities Based Private Line Telecommunications Services Alternative Operator Service Provider

Other (Specify)______________________________________________________________________

STATISTICAL INFORMATION

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UTILITY SHUTOFFS/DISCONNECTS

TOTALS →

OTHER (description):

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

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VERIFICATION

AND

SWORN STATEMENT

DO SAY THAT THIS ANNUAL UTILITY REPORT TO THE ARIZONA CORPORATION COMMISSION

HAS BEEN PREPARED UNDER MY DIRECTION, FROM THE ORIGINAL BOOKS, PAPERS AND RECORDS OF SAID UTILITY; THAT I HAVE CAREFULLY EXAMINED THE SAME, AND DECLARE THE SAME TO BE A COMPLETE AND CORRECT STATEMENT OF BUSINESS AND AFFAIRS OF SAID UTILITY FOR THE PERIOD COVERED BY THIS REPORT IN RESPECT TO EACH AND EVERY MATTER AND THING SET FORTH, TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF.

SWORN STATEMENT

IN ACCORDANCE WITH THE REQUIREMENT OF TITLE 40, ARTICLE 8, SECTION 40- 401, ARIZONA REVISED STATUTES, IT IS HEREIN REPORTED THAT THE GROSS OPERATING REVENUE OF SAID UTILITY DERIVED FROM ARIZONA INTRASTATE UTILITY OPERATIONS DURING CALENDAR YEAR 2020 WAS:

Arizona Intrastate Gross Operating Revenues Only ($)

$___________________________

(THE AMOUNT IN BOX ABOVE

INCLUDES $_________________

IN SALES TAXES BILLED, OR COLLECTED)

TELEPHONE NUMBER

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VERIFICATION

AND

SWORN STATEMENT

RESIDENTIAL REVENUE

DO SAY THAT THIS ANNUAL UTILITY REPORT TO THE ARIZONA CORPORATION COMMISSION

HAS BEEN PREPARED UNDER MY DIRECTION, FROM THE ORIGINAL BOOKS, PAPERS AND RECORDS OF SAID UTILITY; THAT I HAVE CAREFULLY EXAMINED THE SAME, AND DECLARE THE SAME TO BE A COMPLETE AND CORRECT STATEMENT OF BUSINESS AND AFFAIRS OF SAID UTILITY FOR THE PERIOD COVERED BY THIS REPORT IN RESPECT TO EACH AND EVERY MATTER AND THING SET FORTH, TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF.

SWORN STATEMENT

IN ACCORDANCE WITH THE REQUIREMENTS OF TITLE 40, ARTICLE 8, SECTION 40- 401.01, ARIZONA REVISED STATUTES, IT IS HEREIN REPORTED THAT THE GROSS OPERATING REVENUE OF SAID UTILITY DERIVED FROM ARIZONA INTRASTATE UTILITY OPERATIONS RECEIVED FROM RESIDENTIAL CUSTOMERS DURING CALENDAR YEAR 2020 WAS:

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FINANCIAL INFORMATION

Income Statements:

Attach to this annual report a copy of the company’s year-end (Calendar Year 2020) financial statements.

Alternative templates are provided for this information. Please select one from Figure 1A, Figure 1B or Figure 1C.

(All Facilities-Based CLECs, Facilities-Based IXCs, Facilities-Based Access Line Providers & Facilities-Based Private Line Providers must submit FIGURE 1C)

Arizona Administrative Code, R14.2.1115.F, states that one of the items required in this Annual Report is a statement of income for the reporting year

Balance Sheets:

Alternative templates are provided for this information. Please select one from Figure 2A or Figure 2B.

(All Facilities-Based CLECs, Facilities-Based IXCs, Facilities-Based Access Line Providers & Facilities-Based Private Line Providers must submit FIGURE 2B)

Arizona Administrative Code, R14.2.1115.F, states that one of the items required in this Annual Report is a balance sheet as of the end of the reporting year

ALL INFORMATION MUST BE ARIZONA-SPECIFIC AND REFLECT OPERATING

RESULTS IN ARIZONA.

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Docket No. _____________________Year Ending: 12-31-20

Company Name: ___________________________________________________

FIGURE 1A

Revenues:

Expenses:

Operating Income:

Net Income:

Attachment 1

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