Q-2, r. 21 - Regulation respecting waterworks and sewer services

Schedule Disposition versions

2012-09-01

FORM 11

(s. 51)

GOUVERNEMENT DU QUÉBEC

MINISTÈRE DU DÉVELOPPEMENT DURABLE, DE L’ENVIRONNEMENT ET DES PARCS

WATERWORKS SERVICES AND SEWER SERVICES OPERATED BY PERSONS

ANNUAL REPORT FOR THE YEAR ENDING 31 DECEMBER 20___

Note: This report must be forwarded to the Ministère du Développement durable, de l’Environnement et des Parcs, not later than 31 January 20___ Retain a copy for your files. Submit a separate report for each service (waterworks or sewer) where applicable.

_____________________________________________________________________________

Name: _________________________________ Permit No: ____________________________

Address: _____________________________________________________________________

Municipalities served (clearly define the designation of each municipality):

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Type of service: waterworks ______________________ or sewer ____________

_____________________________________________________________________________

Number of subscribers added in 20 ____: ___________________________________________

Alterations to the system in 20 ____ (Replacement or extension of conduits, purchase of devices, setting up of new supply sources, etc.)

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

(it this space is not sufficient, use a separate sheet)

	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		
	

N.B. The waterworks and sewer services which submitted a financial statement to shareholders or users at the last annual meeting must attach a copy thereof to this report.

_____________________________________________________________________________

Date of collection of subscriptions _________________________________________________

Is the subscription payable in advance? _____________________________________________

_____________________________________________________________________________

I certify that the answers hereinabove are complete and exact.

Name of person giving

the information ___________________________________

(name)

___________________________________

(function)

___________________________________

(address)

Date: this_______________ 20____

R.R.Q., 1981, c. Q-2, r. 7, Form 11.