Form Tceq 10516 – Fill Out and Use This PDF

APPLICATION FOR SALE, TRANSFER,

OR MERGER OF A RETAIL PUBLIC UTILITY

TABLE OF CONTENTS
Application For Sale, Transfer Or Merger Of A Retail Public Utility	2
Information That Apply To The Transferor (Current Service Provider Or Seller)	2
Information That Apply To The Transferee Or Purchaser	3
Texas Comptroller Of Public Accounts	4
Information That Apply To More Than Two Parties Involved In This Transaction	5
Historical Balance Sheets	8
Historical Income Statement	9
Historical Expenses Statement	10
Projected Balance Sheets	11
Projected Income Statement	12
Projected Income Statement Conerning General/Administrative Expenses	13
Projected Sources And Uses Of Cash Statements	14
Information That Apply To The Physically Distinct System Being Transferred Or Acquired	15
Information That Apply To The Franchise Agreement Or Consent Letter From The City Or District	15
Oath For Seller Or Former Service Provider	17
Oath For Purchaser Or Acquiring Entity	18
Notice To Current Customers, Neighboring Systems And Cities	19
Notice To Current Customers, Neighboring Systems, Landowner And Cities	21

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10.Contact person. Please provide information about the person to be contacted regarding this application.

Indicate if this person is the owner, operator, engineer, attorney or accountant.

Name: Title:

Address:			Telephone (AC):
Fax #			Email
Relationship to the applicant:

☞IF THERE ARE MORE THAN TWO PARTIES INVOLVED IN THIS

TRANSACTION, PLEASE ATTACH SHEETS PROVIDING

THE INFORMATION REQUIRED IN QUESTION 6 THROUGH QUESTION 10 FOR EACH PARTY

11.Please respond to each of the following questions. Attach additional sheets if necessary.

A.Describe the experience and qualifications of the applicant to provide adequate utility service to the requested area

B.Has the applicant acquiring the CCN or facilities or an affiliated interest of the applicant been under enforcement action by the TCEQ, Texas Department of Health (TDH), the Office of the Attorney General (OAG) or the Environmental Protection Agency (EPA) in the past for noncompliance with

rules, orders or State Statutes?		Yes		No

If yes, please attach copies of any correspondence with these regulatory agencies concerning these enforcement actions and describe any actions and efforts to comply with those requirements. Attach additional sheets if needed.

C.Describe the source and availability of funds required to make the planned or required improvements, if any, to meet minimum requirements of the TCEQ and ensure continuous and adequate service.

D.Describe the anticipated impact of this transaction on the quality of utility service and explain any anticipated changes in the quality of service.

E.How will the transaction serve the public interest?

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12.Please describe the nature of the proposed transaction:

13.If the transferee applicant is an Investor Owned Utility (IOU) and will be under the rate jurisdiction of the TCEQ, please provide the following information. Water supply or sewer service corporations and political subdivisions of the state should mark this section N/A:

A.• Total Purchase Price:

• Total Original Cost (as recorded on books of seller or merging entity):

•Accumulated Depreciation as of the proposed effective date of the transaction:

•Contributions in Aid of Construction:

- Specific surcharges approved by TCEQ: - Revenues from explicit customer agreements:

- Developer Contributions (please explain):

- Other Contributions (please explain):

Total Contributions in Aid of Construction

• Net Book Value:

☞If the Original Cost or any of the above items has been established in a rate case proceeding by the PUC, the TWC or the TCEQ, please provide the Application/Docket Number and date:

Application/Docket Number: Date:

☞If the applicant is not under the rate jurisdiction of the TCEQ, only the purchase price and information related to Contributions in Aid of Construction is required.

B.Please provide any other information concerning the nature of the transaction you believe should be given consideration if not explained elsewhere in the application.

[attach additional sheet(s) if necessary]:

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C.Complete the following proposed entries listed below as shown in books of purchasing (or surviving) company. Additional entries may be made; the following are suggested only, and not

intended to pose descriptive limitations.

Utility Plant in Service: Plant Acquisition Adjustment: Extraordinary Loss on Purchase:

Accumulated Depreciation of Plant:

Cash:

Notes Payable:

Mortgage Payable: Others (please list):

As the purchaser, I understand that it is my responsibility in any future rate proceeding to provide written evidence and support for the original cost and installation date of all facilities used and useful for providing utility service.

Purchaser’s Initials: Date:

14.Please indicate the proposed effect of this transaction on the rates to be charged to the affected customers:

All the customers will be charged the same rates as they were charged before the transaction.

Some All customers will be charged different rates than they were charged before the transaction.

If rates are changing, please explain:

Applicant is an IOU and intends to file with the Commission or municipal regulatory authority an application to change rates of some/all of its customers as a result of this transaction. If so, please explain:

Other. Please explain:

15.List all neighboring water and /or sewer utilities, cities, and political subdivisions providing the same service within two (2) miles of area affected by this proposed transaction. This information should be available from the water utility database (WUD) or Applicant’s licensed water operator.

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16. Financial, Managerial and Technical information for the acquiring entity.

HISTORICAL BALANCE SHEETS

CURRENT A-1 YEAR A-2 YEAR A-3 YEAR A-4 YEAR A-5 YEAR

YEAR (A)

CURRENT ASSETS

Cash

Accounts Receivable

Inventories

Income Tax Receivable

Other

Total

FIXED ASSETS

Land

Collection/Distribution System

Buildings

Equipment

Other

Less: Accum. Depreciation or Reserves

Total

TOTAL ASSETS

CURRENT LIABILITIES

Accounts Payable

Notes Payable, Current

Accrued Expenses

Other

TOTAL

LONGTERM LIABILITIES

Notes Payable, Long-term

Other

TOTAL LIABILITIES

OWNER'S EQUITY

Paid in Capital

Retained Equity

Other

Current Period Profit or Loss

TOTAL OWNER'S EQUITY

TOTAL LIABILITIES AND EQUITY

WORKING CAPITAL

CURRENT RATIO

DEBT TO EQUITY RATIO EQUITY

TO TOTAL ASSETS

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HISTORICAL INCOME STATEMENT

CURRENT A-1 YEAR A-2 YEAR A-3 YEAR A-4 YEAR A-5 YEAR

YEAR (A)

METER NUMBER

Existing Number of Taps

New Taps Per Year

Total Meters at Year End

METER REVENUE

Fees Per Meter

Cost Per Meter

Operating Revenue Per Meter

GROSS WATER REVENUE

Fees

Other

Gross Income

OPERATING EXPENSES

General & Administrative

Interest

Other

NET INCOME

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HISTORICAL EXPENSES STATEMENT

CURRENT A-1 YEAR A-2 YEAR A-3 YEAR A-4 YEAR A-5 YEAR

YEAR (A)

GENERAL/ADMINISTRATIVE

EXPENSES

Salaries

Office Expense

Computer Expense

Auto Expense

Insurance Expense

Telephone Expense

Utilities Expense

Depreciation Expense

Property Taxes

Professional Fees

Other

Total

% Increase Per Year

OPERATIONAL EXPENSES

Salaries

Auto Expense

Utilities Expense

Depreciation Expense

Repair & Maintenance

Supplies

Other

Total

% Increase Per Year

ASSUMPTIONS

Interest Rate/Terms

Utility Cost/gal.

Depreciation Schedule

Other

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PROJECTED BALANCE SHEETS

START UP YEAR 1 YEAR 2 YEAR 3

YEAR 4

YEAR 5

CURRENT ASSETS

Cash

Accounts Receivable

Inventories

Income Tax Receivable

Other

Total

FIXED ASSETS

Land

Collection/Distribution System

Buildings

Equipment

Other

Less: Accum. Depreciation or Reserves

Total

TOTAL ASSETS

CURRENT LIABILITIES

Accounts Payable

Notes Payable, Current

Accrued Expenses

Other

Total

LONGTERM LIABILITIES

Notes Payable, Long-term

Other

TOTAL LIABILITIES

OWNER'S EQUITY

Paid in Capital

Retained Equity

Other

Current Period Profit or Loss

TOTAL OWNER'S EQUITY

TOTAL LIABILITIES AND EQUITY

WORKING CAPITAL

CURRENT RATIO

DEBT TO EQUITY RATIO

EQUITY TO TOTAL ASSETS

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PROJECTED INCOME STATEMENT

YEAR 1 YEAR 2

YEAR 3

YEAR 4 YEAR 5

TOTALS

METER NUMBER

Existing Number of Taps

New Taps Per Year

Total Meters at Year End

METER REVENUE

Fees Per Meter

Cost Per Meter

Operating Revenue Per Meter

GROSS WATER REVENUE

Fees

Other

Gross Income

OPERATING EXPENSES

General & Administrative

Interest

Other

NET INCOME

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PROJECTED INCOME STATEMENT

YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 TOTALS

GENERAL/ADMINISTRATIVE EXPENSES

Salaries

Office Expense

Computer Expense

Auto Expense

Insurance Expense

Telephone Expense

Utilities Expense

Depreciation Expense

Property Taxes

Professional Fees

Other

Total

% Increase Per Year

OPERATIONAL EXPENSES

Salaries

Auto Expense

Utilities Expense

Depreciation Expense

Repair & Maintenance

Supplies

Other

Total

% Increase Per Year

ASSUMPTIONS

Interest Rate/Terms

Utility Cost/gal.

Depreciation Schedule

Other

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PROJECTED SOURCES AND USES OF CASH STATEMENTS

YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 TOTALS

SOURCES OF CASH

Net Income

Depreciation (If Funded)

Loan Proceeds

Other

Total Sources

USES OF CASH

Net Loss

Principle Portion of Pmts.

Fixed Asset Purchase

Reserve

Other

Total Uses

NET CASH FLOW

DEBT SERVICE COVERAGE

Cash Available for Debt

SERVICE (CADS)

Net Income (Loss)

Depreciation, or Reserve Interest

Total

REQUIRED DEBT SERVICE (RDS)

Principle Plus Interest

DEBT SERVICE COVERAGE RATIO

CADS Divided by RDS

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☞PLEASE ANSWER QUESTIONS 17 THROUGH 22 ON A DIFFERENT SHEET

FOR EACH PHYSICALLY DISTINCT SYSTEM BEING

TRANSFERRED OR ACQUIRED

17. A. For Water Systems. TCEQ Public Water System Identification Number:

Date of last inspection:

B. For Wastewater Systems:

-TCEQ Discharge Permit Number:

W Q

-

-Name of Permitee:

-Date of application to transfer Discharge Permit submitted:

-Date of application to transfer Discharge Permit approved by TCEQ:

18. A. Are any improvements required to meet TCEQ standards?

Yes

No. If yes, please explain:

B. Is there a moratorium on new connections?			Yes		No. If yes, please explain:

C.Provide details of each required major capital improvement to correct the deficiencies and meet the TCEQ standards (attach additional sheets if necessary):

	Description of the Required Improvement	Schedule to Complete	Estimated Cost

19.Does the system being transferred operate within the city limits of a municipality or within district

boundaries? Yes No

☞

Attach copy of franchise agreement or consent letter from the

city

or

district.

20. Do you currently purchase water or sewer treatment capacity from another source?

Yes

No

Water

Sewer

Purchased on a

Regular

Seasonal

Emergency Basis

•Source: % of total supply:

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OATH FOR SELLER OR FORMER SERVICE PROVIDER

STATE OF

COUNTY OF

I,				,being duly sworn, file this application for
sale, lease, rental or merger or consolidation as

(indicate relationship to applicant) that is, owner, member of partnership, title as officer of corporation, or other authorized representative of applicant); that, in such capacity, I am qualified and authorized to file and verify such application, am personally familiar with the documents filed with this application, and have complied with all the requirements contained in the application; and, that all such statements made and matters set forth therein with respect to applicant are true and correct. Statements about other parties are made on information and belief. I further state that the application is made in good faith and that this application does not duplicate any filing presently before the Commission.

I further state that I have provided to the purchaser or transferee a written disclosure statement about any contributed property as required under Section 13.301(j) and copies of any outstanding Orders of the Commission or Attorney General and have also complied with the notice requirements in Section 13.301(k) of the Water Code.

AFFIANT

(Utility’s Authorized Representative)

If the Affiant to this form is any person other than the sole owner, partner, officer of the Applicant, or its attorney, a properly verified Power of Attorney must be enclosed.

SUBSCRIBED AND SWORN TO BEFORE ME, a Notary Public in and for the State of Texas,

day of , 20 .

SEAL

NOTARY PUBLIC IN AND FOR THE

STATE OF TEXAS

PRINT OR TYPE NAME OF NOTARY

MY COMMISSION EXPIRES

One copy of this page must be submitted for each utility involved in this transaction.

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OATH FOR PURCHASER OR ACQUIRING ENTITY

STATE OF

COUNTY OF

I,

,being duly sworn, file this application for

sale, lease, rental or merger or consolidation as (indicate relationship to applicant) that is, owner, member of partnership, title as officer of corporation, or other authorized representative of applicant); that, in such capacity, I am qualified and authorized to file and verify such application, am personally familiar with the documents filed with this application, and have complied with all the requirements contained in the application; and, that all such statements made and matters set forth therein with respect to applicant are true and correct. Statements about other parties are made on information and belief. I further state that the application is made in good faith and that this application does not duplicate any filing presently before the Commission.

I am also authorized and do agree to be bound by and comply with any outstanding orders of the Commission or the Attorney General which have been issued to the system or facilities being acquired and recognize that I will be subject to administrative penalties or other enforcement actions if I do not comply.

AFFIANT

(Utility’s Authorized Representative)

If the Affiant to this form is any person other than the sole owner, partner, officer of the Applicant, or its attorney, a properly verified Power of Attorney must be enclosed.

Applicant represents that all other parties to this transaction have been furnished copies of this completed application.

SUBSCRIBED AND SWORN TO BEFORE ME, a Notary Public in and for the State of Texas,

day of , 20 .

SEAL

NOTARY PUBLIC IN AND FOR THE

STATE OF TEXAS

PRINT OR TYPE NAME OF NOTARY

MY COMMISSION EXPIRES

One copy of this page must be submitted for each utility involved in this transaction.

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FORM A	Application No.	____________________
	Notice to Current Customers, Neighboring Systems and Cities

‘S

(Seller’s or Transferor’s Name)

NOTICE OF INTENT TO SELL FACILITIES AND TRANSFER CERTIFICATE OF CONVENIENCE AND

NECESSITY (CCN) NO TO

						(Purchaser’s or Transferee’s Name)
IN						COUNTY, TEXAS
To:					Date Notice Mailed				, 20
				(Name of Customer, Neighboring System or City)

	(Address)
City	State	Zip
	Sellers or Transferors’ Name		Address	City/State/Zip Code

has submitted an application with the Texas Commission on Environmental Quality to sell facilities and transfer

water or sewer (please select) CCN No.				in				[County Name]
County to:
Purchasers or Transferee’s Name			Address				City/State/Zip Code

The sale is scheduled to take place as approved by the Executive Director (V.T.C.A., Water Code §13.301). The transaction and the transfer of the CCN include the following subdivision(s) and zip codes:

The area subject to this transaction is located approximately

miles

[direction] of

downtown

,[City or Town] Texas, and is generally bounded on the north by

;on the east by

;on the south by

;and on the west by

The total area being requested includes approximately

acres and serves

current customers.

This transaction will have the following effect on the current customer's rates and services:

TCEQ-10516 (REV 09/2012)

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Affected persons may file written protests and/or request a public hearing within 30 days of this notice.

To request a hearing, you must:

(1)state your name, mailing address and daytime telephone number;

(2)state the applicant's name, application number or another recognizable reference to this application;

(3)include the statement "I/we request a public hearing”;

(4)write a brief description of how you, the persons you represent, or the public interest would be adversely affected by the proposed transaction and transfer of the CCN; and

(5)state your proposed adjustment to the application or CCN which would satisfy your concerns and cause you to withdraw your request for a hearing.

Only those persons who submit a written request to be notified of a hearing will receive notice if a hearing is scheduled. The Executive Director will issue the CCN requested in the referenced application unless a hearing is scheduled to consider the transaction. If no protests or requests for hearing are filed during the comment period, the Executive Director may issue the CCN 30 days after publication of this notice.

Persons who wish to protest or request a hearing on this application should write the: Texas Commission on Environmental Quality

Water Supply Division

Utilities and Districts Section, MC-153

P. O. Box 13087, Austin, TX 78711-3087

Se desea informacion on Espanol, puede llamar al 512-239-0200.

Utility Representative

Utility Name

TCEQ-10516 (REV 09/2012)

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FORM B

Application No.

Notice to Current Customers, Neighboring Systems, Landowner and Cities

	‘S NOTICE OF INTENT TO SELL FACILITIES TO
(Seller’s or Transferor’s Name)
		AND FOR
(Purchaser’s or Transferee’s Name)				Purchaser’s or Transferee’s Name)

TO OBTAIN OR AMEND A CERTIFICATE OF CONVENIENCE AND NECESSITY (CCN) IN COUNTY, TEXAS

To:						Date Notice Mailed				, 20
(Name of Customer, Neighboring System, Landowner or City)
			(Address)
		City	State	Zip
Sellers or Transferors’ Name					Address			City/State/Zip Code

has submitted an application with the Texas Commission on Environmental Quality to sell water or sewer (please

select) Facilities in				[County Name] County to:
Purchasers or Transferee’s Name			Address	City/State/Zip Code

The transferee has also requested to obtain/amend a CCN in this application. The sale is scheduled to take place as approved by the Executive Director (V.T.C.A., Water Code §13.301). The transaction and the proposed service area include the following subdivision(s) and zip codes:

The area subject to this transaction is located approximately

miles

[direction] of

downtown

,[City or Town] Texas, and is generally bounded on the north by

;on the east by

;on the south by

;and on the west by

The total area being requested includes approximately

acres and serves

current customers.

This transaction will have the following effect on the current customer's rates and services:

TCEQ-10516 (REV 09/2012)

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Affected persons may file written protests and/or request a public hearing within 30 days of this notice.

To request a hearing, you must:

(1)state your name, mailing address and daytime telephone number;

(2)state the applicant's name, application number or another recognizable reference to this application;

(3)include the statement "I/we request a public hearing”;

(4)write a brief description of how you, the persons you represent, or the public interest would be adversely

affected by the proposed transaction and transfer of the CCN; and

(5)state your proposed adjustment to the application or CCN which would satisfy your concerns and cause you to withdraw your request for a hearing.

Only those persons who submit a written request to be notified of a hearing will receive notice if a hearing is scheduled. The Executive Director will issue the CCN requested in the referenced application unless a hearing is scheduled to consider the transaction. If no protests or requests for hearing are filed during the comment period, the Executive Director may issue the CCN 30 days after publication of this notice.

Persons who wish to protest or request a hearing on this application should write the:

Texas Commission on Environmental Quality

Water Supply Division

Utilities and Districts Section, MC-153

P. O. Box 13087, Austin, TX 78711-3087

Se desea informacion on Espanol, puede llamar al 512-239-0200.

Utility Representative

Utility Name

TCEQ-10516 (REV 09/2012)

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