The Arizona Annual Report form is a crucial document that businesses must file with the Arizona Corporation Commission, detailing their operations for the previous year. This form not only captures essential company information but also ensures compliance with state regulations. By submitting the annual report, companies provide transparency regarding their activities, ownership, and financial status, which is vital for maintaining good standing in Arizona.
The Arizona Annual Report form is a critical document required by the Arizona Corporation Commission for utility companies operating within the state. This form collects essential information regarding the company's identity, including its current business name and any applicable "doing business as" (DBA) names. Companies must provide their mailing address, contact details, and local office information, ensuring that all communication channels are up to date. Management and regulatory contacts are also required, along with details about the statutory agent and attorney, if applicable. The form addresses significant changes that may have occurred during the reporting year, such as ownership changes or compliance notifications from regulatory authorities. Additionally, it requires companies to specify their ownership structure, whether they are a sole proprietor, partnership, corporation, or limited liability company. The report further mandates the identification of counties served and the services authorized to be provided. Lastly, statistical information specific to telecommunications utilities must be reported, including data on access lines, customer numbers, and revenue generated within Arizona. Completing this form accurately is essential for maintaining compliance and ensuring the continued operation of utility services in the state.
ARIZONA CORPORATION COMMISSION
UTILITIES DIVISION
ANNUAL REPORT MAILING LABEL – MAKE CHANGES AS NECESSARY
Please click here if pre-printed Company name on this form is not your current Company name or dba name is not included.
Please list current Company name including dba here:
__________________________________________________________________________
ANNUAL REPORT
FOR YEAR ENDING
12
31
2020
FOR COMMISSION USE
ANN 03
20
COMPANY INFORMATION
Company Name (Business Name) _________________________________________________________
Mailing Address ____________________________________________________________________________
(Street)
_________________________________________________________________________________________
(City)(State)(Zip)
__________________________________________________________________________________________
Telephone No. (Include Area Code)Fax No. (Include Area Code)Cell No. (Include Area Code)
Email Address______________________________________________________________________________
Local Office Mailing Address _______________________________________________________________
__________________________________________________________1-800-___________________________
Customer Service Phone No. (Include Area Code)
Website address ___________________________________________________________________________
MANAGEMENT INFORMATION
Management Contact:_________________________________________________________________________________
(Name)(Title)
_______________________________________________________________________________________________________________________
(City)
(State)
(Zip)
Telephone No. (Include Area Code)
Fax No. (Include Area Code)
Cell No. (Include Area Code)
Regulatory Contact:___________________________________________________________________
(Name)
2
Statutory Agent:__________________________________________________________________________
________________________________________________________________________________________________________________________
(Street)(City)(State)(Zip)
____________________________________________________________________________________________________________
Telephone No. (Include Area Code)Fax No. (Include Area CodeCell No. (Include Area Code)
Attorney:________________________________________________________________________________
Email Address:_____________________________________________________________________________
Important Changes During the Year
Yes __ No __
For those companies not subject to the affiliated interest rules, has there been a change in ownership or direct control during the year?
If yes, please provide specific details in the box below.
Has the company been notified by any other regulatory authorities during the year that they are out of compliance?
3
OWNERSHIP INFORMATION
Check the following box that applies to your company:
Sole Proprietor (S)
Partnership (P)
Bankruptcy (B)
Receivership (R)
CCorporation (C) (Other than Association/Co-op) Subchapter S Corporation (Z)
Association/Co-op (A) Limited Liability Company
Other (Describe)______________________________________________________________________
COUNTIES SERVED
Check the box below for the counties in which you are certificated to provide service:
STATEWIDE
APACHE
GILA
LA PAZ
NAVAJO
SANTA CRUZ
COCHISE
GRAHAM
MARICOPA
PIMA
YAVAPAI
COCONINO
GREENLEE
MOHAVE
PINAL
YUMA
4
SERVICES AUTHORIZED TO PROVIDE
Check the following box(es) for the services that you are authorized to provide:
Resold Long Distance/Interexchange Telecommunications Services (RLD) Resold Local Exchange Telecommunications Services (RLEC)
Facilities-Based Long Distance/Interexchange Telecommunications Services (IXC) Facilities Based Local Exchange Telecommunications Services (CLEC)
Facilities Based Private Line Telecommunications Services Alternative Operator Service Provider
Other (Specify)______________________________________________________________________
STATISTICAL INFORMATION
TELECOMMUNICATION UTILITIES ONLY
Total number of residential local exchange access lines
Total number of residential local exchange customers
Total number of business local exchange access lines
Total number of business local exchange customers
Total quantity of phone numbers assigned to Company
Total phone numbers assigned to Customers by Company
Total number of long distance residential customers
Total number of long distance business customers
Total intrastate local exchange revenue from Arizona operations
Total intrastate long distance/interexchange revenue from Arizona operations Total intrastate revenue from Arizona operations
Total intrastate income from Arizona operations
Value of Company’s total assets in Arizona Value of Company’s total assets
(Value of Company’s total assets in Arizona)/(Value of company’s total assets)
Current amount of deposits, prepayments, and advances from customers
(not including monthly service bills)
Current amount of performance bond
Current amount of Irrevocable Sight Draft Letter of Credit
Check box if Company is current on payments for:
Regulatory Assessment
AZ Universal Service Fund
AZ 911/E911
Circuit
Voice over Internet
Switched
Protocol (“VoIP”)
_______________
________________
__________________________________
RetailOther
_______________ ________________
$_________________________________
%_________________________________
AZ Telephone Relay Service
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UTILITY SHUTOFFS/DISCONNECTS
MONTH
Termination without Notice
R14-2-509.B
Termination with Notice
R14-2-509.C
OTHER
TOTALS →
OTHER (description):
6
VERIFICATION
AND
SWORN STATEMENT
STATE OF ________________
I, THE UNDERSIGNED OF THE
Intrastate Revenues Only
COUNTY OF (COUNTY NAME)
NAME (OWNER OR OFFICIAL) TITLE
COMPANY NAME
DO SAY THAT THIS ANNUAL UTILITY REPORT TO THE ARIZONA CORPORATION COMMISSION
FOR THE YEAR ENDING
DAY
YEAR
HAS BEEN PREPARED UNDER MY DIRECTION, FROM THE ORIGINAL BOOKS, PAPERS AND RECORDS OF SAID UTILITY; THAT I HAVE CAREFULLY EXAMINED THE SAME, AND DECLARE THE SAME TO BE A COMPLETE AND CORRECT STATEMENT OF BUSINESS AND AFFAIRS OF SAID UTILITY FOR THE PERIOD COVERED BY THIS REPORT IN RESPECT TO EACH AND EVERY MATTER AND THING SET FORTH, TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF.
IN ACCORDANCE WITH THE REQUIREMENT OF TITLE 40, ARTICLE 8, SECTION 40- 401, ARIZONA REVISED STATUTES, IT IS HEREIN REPORTED THAT THE GROSS OPERATING REVENUE OF SAID UTILITY DERIVED FROM ARIZONA INTRASTATE UTILITY OPERATIONS DURING CALENDAR YEAR 2020 WAS:
Arizona Intrastate Gross Operating Revenues Only ($)
$___________________________
(THE AMOUNT IN BOX ABOVE
INCLUDES $_________________
IN SALES TAXES BILLED, OR COLLECTED)
**REVENUE REPORTED ON THIS PAGE MUST INCLUDE SALES TAXES BILLED OR COLLECTED. IF FOR ANY OTHER REASON, THE REVENUE REPORTED ABOVE DOES NOT AGREE WITH TOTAL OPERATING REVENUES ELSEWHERE REPORTED, ATTACH THOSE STATEMENTS THAT RECONCILE THE DIFFERENCE. (EXPLAIN IN DETAIL)
SIGNATURE OF OWNER OR OFFICIAL
TELEPHONE NUMBER
SUBSCRIBED AND SWORN TO BEFORE ME
A NOTARY PUBLIC IN AND FOR THE COUNTY OF
THIS
DAY OF
(SEAL)
MY COMMISSION EXPIRES____________________________
COUNTY NAME
20__
SIGNATURE OF NOTARY PUBLIC
7
RESIDENTIAL REVENUE
STATE OF ARIZONA
I, THE UNDERSIGNED
OF THE
INTRASTATE REVENUES ONLY
NAME (OWNER OR OFFICIAL)
TITLE
MONTH DAY YEAR
12 31 2020
IN ACCORDANCE WITH THE REQUIREMENTS OF TITLE 40, ARTICLE 8, SECTION 40- 401.01, ARIZONA REVISED STATUTES, IT IS HEREIN REPORTED THAT THE GROSS OPERATING REVENUE OF SAID UTILITY DERIVED FROM ARIZONA INTRASTATE UTILITY OPERATIONS RECEIVED FROM RESIDENTIAL CUSTOMERS DURING CALENDAR YEAR 2020 WAS:
ARIZONA INTRASTATE GROSS OPERATING REVENUES
$_________________________
(THE AMOUNT IN BOX AT LEFT INCLUDES $_____________________________
*RESIDENTIAL REVENUE REPORTED ON THIS PAGE MUST INCLUDE SALES TAXES BILLED.
MY COMMISSION EXPIRES
NOTARY PUBLIC NAME
8
FINANCIAL INFORMATION
Income Statements:
Attach to this annual report a copy of the company’s year-end (Calendar Year 2020) financial statements.
Alternative templates are provided for this information. Please select one from Figure 1A, Figure 1B or Figure 1C.
(All Facilities-Based CLECs, Facilities-Based IXCs, Facilities-Based Access Line Providers & Facilities-Based Private Line Providers must submit FIGURE 1C)
Arizona Administrative Code, R14.2.1115.F, states that one of the items required in this Annual Report is a statement of income for the reporting year
Balance Sheets:
Alternative templates are provided for this information. Please select one from Figure 2A or Figure 2B.
(All Facilities-Based CLECs, Facilities-Based IXCs, Facilities-Based Access Line Providers & Facilities-Based Private Line Providers must submit FIGURE 2B)
Arizona Administrative Code, R14.2.1115.F, states that one of the items required in this Annual Report is a balance sheet as of the end of the reporting year
ALL INFORMATION MUST BE ARIZONA-SPECIFIC AND REFLECT OPERATING
RESULTS IN ARIZONA.
9
Docket No. _____________________Year Ending: 12-31-20
Company Name: ___________________________________________________
FIGURE 1A
Account Description
$ Amount
Revenues:
Expenses:
Operating Income:
Net Income:
Attachment 1
10
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