© Éditeur officiel du Québec
|
Updated to 1 October 2014
This document has official status. |
_______________________________________________________________________
| | | |
| | Designation | |
| Municipality | (city, town, village,)| Number of subscribers |
| | parish or township) | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
________________________________________________________________________________
| | | | | |
| | | Tariffs | Projected | |
| Class | Number | in force | tariffs | Increase |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|House | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|1st faucet | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Additional faucets | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Bath | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Water-closets | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Hose | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Cooler | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Heating | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Automobile | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Hydrants | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Farmers | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Domestic animals | | | | |
|or | | | | |
|Stable | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Presbytery and church * | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|School * | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Convent * | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|College * | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Hotel | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Store | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Commercial or industrial | | | | |
|establishments | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
| | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
| | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Miscellaneous (specify) | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
| *Immovables followed by an asterisk are not subject to rates in the case |
| where the operator of the system is a municipality. |
|________________________________________________________________________________|
6– Details on the actual cost of the system with all its accessories:
A– Supply: (stream, brook, spring or well) Actual cost
Spring or well............................. $________
Land and rights of way..................... $________
Catchment: (dam or basin).................. $________
Water intake............................... $________
B– Water treatment: Filtration................................. $________
Chlorination............................... $________
Building................................... $________
Other means................................ $________
C– Pumping: Pump....................................... $________
Motor...................................... $________
Building................................... $________
D– Reservoirs: ........................................... $________
........................................... $________
E– Canalization: (Branch pipe conduit and accessories or, in
the case of a sewer service, conduit for the
disposal of waste water)
........................................... $________
........................................... $________
........................................... $________
F– Distribution: (Conduits and accessories)
........................................... $________
........................................... $________
........................................... $________
........................................... $________
........................................... $________
........................................... $________
........................................... $________
G– Miscellaneous: (Contingencies, stock and general expenses):
........................................... $________
........................................... $________
TOTAL REAL COST: $________
P.S. If the above space is not sufficient, use a separate sheet and attach it
to your application.
7– A copy of the financial report submitted to the shareholders or partners at
their last annual meeting. In the absence of such report, it will be necessary
to provide a statement of the assets and liabilities and complete the table
hereunder.
________________________________________________________________________________
________________________________________________________________________________
|
INCOME | EXPENDITURES
_______________________________________|________________________________________
A– Receipts from service: | A– Operation and administration costs
| (Annex particulars)
|
Domestic.................... $________| Maintenance................. $________
|
Industrial.................. $________| Repairs..................... $________
|
Public...................... $________| Administration.............. $________
|
Special..................... $________| Discounts................... $________
|
.......................Total $________| Total $________
|
B – Others receipts: |B– Fixed expenses:
|
| Depreciation................ $________
$________|
| Interest.................... $________
|
| Taxes....................... $________
|
| Total: $________
Total: $________|
|
|
C – Additional revenue: |C– Unclassified expenditures:
|
$________| $________
|
$________| $________
|
Total revenue: $________| Total: $________
|
Annual surplus: $________| Total expenditures: $________
|
_______________________________________|________________________________________
Date: __________________ 20____
_______________________________________
Applicant
______________________________________________________________________________
| | |
| | ANNUAL RATE(s) |
| |_____________________________________________|
| | | | |
| CLASS OF SUBSCRIBER | Current | Projected | Increase |
|________________________________|_____________|______________|________________|
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|________________________________|_____________|______________|________________|
______________________________________________________________________________
| | |
| | ANNUAL RATE(S) |
| |_____________________________________________|
| | | | |
| CLASS OF SUBSCRIBER | Current | Projected | Increase |
|________________________________|_____________|______________|________________|
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|________________________________|_____________|______________|________________|
_______________________________________________________________________
| | | | |
| Name of municipality | Name or number | Number of | Number of |
| and designation | of range(s) | subscribers | hydrants |
|________________________|__________________|_____________|_____________|
|________________________|__________________|_____________|_____________|
| | | | |
|________________________|__________________|_____________|_____________|
| | | | |
|________________________|__________________|_____________|_____________|
| | | | |
|________________________|__________________|_____________|_____________|
| | | | |
|________________________|__________________|_____________|_____________|
| | | | |
|________________________|__________________|_____________|_____________|
| | | | |
|________________________|__________________|_____________|_____________|
________________________________________________________________________________
| | | | |
| Length | Diameter | Nature | Year |
|_____________________|____________________|__________________|__________________|
| | | | |
|_____________________|____________________|__________________|__________________|
| | | | |
|_____________________|____________________|__________________|__________________|
| | | | |
|_____________________|____________________|__________________|__________________|
| | | | |
|_____________________|____________________|__________________|__________________|
| | | | |
|_____________________|____________________|__________________|__________________|
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|_____________________|____________________|__________________|__________________|
________________________________________________________________________________
|________________________________________________________________________________|
| || || || |
| Annual tariff for || Name of || Name of || Name of |
| || municipality || municipality || municipality |
|_____________________||__________________||__________________||_________________|
|_____________________||__________________||__________________||_________________|
| || || || |
| || || || |
|_____________________||__________________||__________________||_________________|
| || | || | || | |
| || Number | Tariff || Number | Tariff || Number | Tariff |
| ||_________|________||_________|________||________|________|
| || | || | || | |
| House || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| 1st faucet || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Additional faucets || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Bath || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Water-closets || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Hose || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Cooler || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Heating || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Automobile || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Hydrants || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Farmers || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Animals || | || | || | |
| or || | || | || | |
| Stables || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Presbytery and || | || | || | |
| church * || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| School * || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Convent * || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Hotel || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Store || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Commercial or || | || | || | |
| industrial || | || | || | |
| establishments || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| Miscellaneous || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| || | || | || | |
|_____________________||_________|________||_________|________||________|________|
| || | || | || | |
| || | || | || | |
|_____________________||_________|________||_________|________||________|________|
|________________________________________________________________________________|
| |
| * Immovables followed by an asterisk are not subject to rates in the case |
| where the operator of the system is a municipality. |
|________________________________________________________________________________|
________________________________________________________________________________
|________________________________________________________________________________|
| | | |
| Flow | Pressure | Power |
|________________________|__________________________|____________________________|
|________________________|__________________________|____________________________|
| | | |
|________________________|__________________________|____________________________|
| | | |
|________________________|__________________________|____________________________|
| | | |
|________________________|__________________________|____________________________|
| | | |
|________________________|__________________________|____________________________|
| | | |
|________________________|__________________________|____________________________|
________________________________________________________________________________
|________________________________________________________________________________|
| | | |
| Capacity | Dimensions | Nature |
|________________________|__________________________|____________________________|
|________________________|__________________________|____________________________|
| | | |
|________________________|__________________________|____________________________|
| | | |
|________________________|__________________________|____________________________|
| | | |
|________________________|__________________________|____________________________|
| | | |
|________________________|__________________________|____________________________|
| | | |
|________________________|__________________________|____________________________|
____________________________________________________________________
| | | | |
| Municipality | Designation | Subscribers | Tariff |
|___________________|__________________|_______________|_____________|
|___________________|__________________|_______________|_____________|
| | | | |
|___________________|__________________|_______________|_____________|
| | | | | |
| | | | Item | $ |
|___________________|__________________|_______________|_______|_____|
|___________________|__________________|_______________|_______|_____|
| | | | | |
|___________________|__________________|_______________|_______|_____|
| | | | | |
|___________________|__________________|_______________|_______|_____|
| | | | | |
|___________________|__________________|_______________|_______|_____|
| | | | | |
|___________________|__________________|_______________|_______|_____|
________________________________________________________________________________
| | | | |
| Length | Diameter | Nature | Year |
|_____________________|____________________|__________________|__________________|
|_____________________|____________________|__________________|__________________|
| | | | |
|_____________________|____________________|__________________|__________________|
| | | | |
|_____________________|____________________|__________________|__________________|
| | | | |
|_____________________|____________________|__________________|__________________|
| | | | |
|_____________________|____________________|__________________|__________________|
| | | | |
|_____________________|____________________|__________________|__________________|
| | | | |
|_____________________|____________________|__________________|__________________|
________________________________________________________________________________
| | |
| Flow of pump | Power of motor |
|_______________________________________|________________________________________|
|_______________________________________|________________________________________|
| | |
|_______________________________________|________________________________________|
| | |
|_______________________________________|________________________________________|
| | |
|_______________________________________|________________________________________|
| | |
|_______________________________________|________________________________________|
| | |
|_______________________________________|________________________________________|
_______________________________________________________________________________
| | | |
| Municipality | Designation | Number of subscribers |
|___________________________|___________________|_______________________________|
| | | |
|___________________________|___________________|_______________________________|
| | | |
|___________________________|___________________|_______________________________|
| | | |
|___________________________|___________________|_______________________________|
ASSETS
Overall cost of service, including: lands, rights and servitudes, buildings devices, tools,
materials and installation costs. (This information is important and must be given as
accurately as possible.)
Cash in hand or in bank (other than reserve fund)
Accounts receivable
Reserve fund
Materials and furnishings in hand
Miscellaneous
Total:
LIABILITIES
Paid-up capital
Bonds, mortagnes, loans
Overdrawn bank accounts
Sinking fund liability
Miscellaneous (unpaid interest, bills payable, etc.)
Surplus
Total:
REVENUE
Receipts from subscriptions
Receipts from assessments in the case of a partnership or syndicate
Other receipts
Total:
EXPENDITURES
{salaries:
Administration: {stationery, insurance, heating, postage, lighting, rent,
{furniture, etc.
Maintenance salary and machinery:
and repair {material:
{electritcity:
Improvement, extension, {salary and machinery:
alteration work, {materials:
new facilities: {miscellaneous:
Taxes:
Interest:
Dividends:
Miscellaneous:
Total
ASSETS
Overall cost of service, including: lands, rights and servitudes, buildings devices, tools,
materials and installation costs.
Cash in hand or in bank (other than reserve fund)
Accounts receivable
Reserve fund
Materials and furnishings in hand
Miscellaneous
Total:
LIABILITIES
Paid-up capital
Bonds, mortagnes, loans
Overdrawn bank accounts
Sinking fund liability
Miscellaneous (unpaid interest, bills payable, etc.)
Surplus
Total:
REVENUE
Receipts from subscriptions
Receipts from special taxes which apply to the public service in question
Other receipts
Total:
EXPENDITURES
{salaries:
Administration: {stationery, insurance, heating, postage, lighting, rent,
{furniture, etc.
Maintenance salary and machinery:
and repair: {material:
{electritcity:
Improvement, extension, {salary and machinery:
alteration work, {materials:
new facilities: {miscellaneous:
Taxes:
Interest:
Dividends:
Miscellaneous:
Total