ReportofConnecticutIntrastateGrossRevenues-CT.gov.doc

CPPU USE ONLY App #:________________________________ Doc #:________________________________ _____________________________________ Report of Connecticut Intrastate Gross Revenues Please submit this completed Reporting Form, to: CENTRAL PERMIT PROCESSING UNIT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM STREET HARTFORD, CT 06106-5127 All regulated companies, as defined under section 16-49(a)(1) of the Connecticut General Statutes (CGS), shall report annually, on or before May 1st, its intrastate gross revenues of the preceding calendar year to the Public Utilities Regulatory Agency (PURA) of the Connecticut Department of Energy and Environmental Protection (DEEP) by completing and submitting this form to the address indicated above. NOTE: All companies must file this form regardless of the amount of intrastate gross revenues for the preceding calendar year, even if the amount is zero. Failure to file this fully completed report with a postmark of no later than May 1st may subject the company to a penalty of $10,000 in accordance with CGS §16-41. Reports filed to an address other than that specified above and/or failure to file an original copy of the report may subject the filer to penalties. Part I: Company Information If an applicant is a corporation, limited liability company, limited partnership, limited liability partnership, or a statutory trust, it must be registered with the Secretary of State. If applicable, the applicant’s name shall be stated exactly as it is registered with the Secretary of State. Please note, for those entities registered with the Secretary of State, the registered name will be the name used by DEEP. This information can be accessed at the Secretary of States database (CONCORD). (/CONCORD/index.jsp) 1. Company Name: Mailing Address: City/Town: State: Zip Code: Business Phone: ext.: Contact Person: Phone: ext. *E-mail: Website (if available): *By providing this e-mail address you are agreeing to receive of