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Q-2, r. 21 - Regulation respecting waterworks and sewer services
Schedule
Disposition versions
FORM 12
(s. 55)
GOUVERNEMENT DU QUÉBEC
MINISTÈRE DU DÉVELOPPEMENT DURABLE, DE L’ENVIRONNEMENT ET DES PARCS
WATERWORKS SERVICES AND SEWER SERVICES OPERATED BY A MUNICIPALITY
SERVING OUTSIDE ITS TERRITORIAL LIMITS
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 users added on the entire system in 20 _____: _______________________________
Number of users added outside the municipal limits in 20 _____: _________________________
Total number of users served on the entire system at 31 December 20 _____: ________________
Total number of users served outside the municipal limits at 31 December 20 ____ : __________
Alterations to the system in 20 ____ (Replacement or extension of conduits, purchase of devices, setting up of new supply sources, etc, both to the system in general as well as to the part outside the municipal limits. Indicate separately the alterations made outside the municipal limits).
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
(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.
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
N.B. The municipalities which submitted a financial statement to taxpayers 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____
