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PRIVATE NONPROFIT SPECIAL NEEDS TRANSPORTATION PROVIDERS 2016 ANNUAL REPORT FOR dba: (REGISTERED NAME OF BUSINESS) (OFFICIAL MAILING ADDRESS) (CITY) (STATE) Please check if address listed above is an updated address Report Year Ended: December 31, 2016 Inquiries concerning this Annual Report should be addressed to: Name/Title: Address: City: State/Zip: Telephone: Email: SUBMIT TO: WASHINGTON UTILITIES AND TRANSPORTATION COMMISSION PO Box 47250 Olympia, WA 98504-7250 File online: www.utc.wa.gov REPORT MUST BE RECEIVED NO LATER THAN MAY 1, 2017 Please refer to the Instructions for Completing the Annual Report on Page 2 S N n Page 2 (ZIP) INSTRUCTIONS FOR ANNUAL REPORT COMPLETION Commission Authority The purpose of this form is to collect financial and operational information from nonprofit transportation providers regulated by the Washington Utilities and Transportation Commission (UTC).. Regulatory Fee Calculations 1 Total Number of vehicles operated at any time during the regulatory year 2 Total Regulatory Fees owed (enter amount from Line 1) x Agency Use O Penalty Interest Calculations 3 Penalties on Regulatory Fees being paid after May 1 4 Total Penalties on Regulatory Fees owed (enter amount from Line 2 x 2 ) x 5 Interest on Regulatory Fees being paid after May 31 6 Amount from Line 2 x Number of month past May 31 x 1 x x 7 Total Penalties and Interest owed (Line 4 plus Line 6) 8 Total Regulatory, Penalties and Interest Fees Due (Line 2 plus Line 7) Agency Use O COMMISSION USE ONLY Reception : Reference: 001-111-0268-231-01 AR2016 001-111-0268-231-11 Payment ID: 001-111-0268-032-20 001R-111-0268-032-20 Total Paid: -Page 5- ( Annual Report Year 2016 ers to file reports the number of ed..
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