Annual Railroad Report
|
|
- Richard Patterson
- 6 years ago
- Views:
Transcription
1 Annual Railroad Report OF THE COMPANY ADDRESS FOR THE YEAR ENDING DECEMBER 31, 2017 TO THE LOUISIANA TAX COMMISSION Post Office Box Baton Rouge, LA
2 1 RAILROAD REPORT OF THE MADE TO THE LOUISIANA TAX COMMISSION (UNDER ACT 703 OF 1976) For the Year Ending December 31, 2017 Schedules to be filed with the Louisiana Tax Commission, Post Office Box 66788, Baton Rouge, LA 70896, on or before April 1 st. If a corporation, indicate the State or Country of incorporation: Location of principal office: Location of principal business establishment in Louisiana: Location of primary business connection in Louisiana: Name of Company Agent: Address of Such Agent: Name of Agent upon whom process may be served: Address of Such Agent: Prepared By: Phone Number: Name and Address of Officer to whom correspondence concerning this report should be addressed: NAME: ADDRESS: TITLE: PHONE NUMBER: CITY STATE ZIP CODE FAX NUMBER: NAME AND ADDRESS OF OFFICERS TITLE NAME ADDRESS PRESIDENT: VICE-PRESIDENT: SECRETARY: TREASURER: GENERAL MANAGER: GEN. SUPERINTENDENT: Railroad Report1.doc 12/22/2017
3 1A CAPITAL STOCK DESCRIPTION OF CAPITAL STOCK PAR VALUE OF SHARES TOTAL PAR VALUE AUTHORIZED TOTAL AMOUNT ISSUED AND OUTSTANDING MARKET PRICE PER SHARE THE AVERAGE PRICE PER SHARE FOR WHICH STOCK SOLD DURING YEAR ENDED DECEMBER 31 AMOUNT OF DIVIDEND PAID PER SHARE DURING YEAR ENDED DECEMBER 31 Common Preferred Railroad Report1A.doc 12/22/2017
4 2 FUNDED DEBT Mortgage Bonds, Miscellaneous Obligations, Income Bonds, Equipment Trust Obligations, Conditional Sale Agreements, etc., as of December 31, DESCRIPTION OF EACH ISSUE OR SERIES OF FUNDED DEBT AND EQUIPMENT OBLIGATIONS BY NAME AS DESIGNATED IN RECORDS OF THE COMPANY DATE OF ISSUE WHEN DUE AMOUNT ISSUED AND OUTSTANDING INTEREST RATE AVERAGE MARKET VALUE YEAR ENDED DECEMBER 31. YEAR 2011 YEAR 2012 YEAR 2013 NOTE: Show here how the average market price per share for stock and average market value for Funded Debt, as shown above, was determined. Railroad Report2.doc 12/22/2017
5 3 ITEM NUMBER 1 Railway Operating Revenue 2 All Track Miles 3 Car and Locomotive Miles 4 Ton and Passenger Miles STATISTICS FOR YEAR ENDED DECEMBER 31, 2017 ITEMS 5 Undepreciated Investment in Road (Accounts 1-45) ENTIRE SYSTEM APPLICABLE TO STATE OF LOUISIANA RATIO Railroad Report3.doc
6 4 RECAPITULATION STATEWIDE Show mileage by Main Line and All Branches. DESCRIPTION MILES OF MAIN TRACK MILES OF SECOND MAIN TRACK MILES OF SIDE TRACK REAL ESTATE OTHER PROPERTY TOTALS: Railroad Report4.doc
7 5 MAIN LINE/BRANCH Under this schedule, report all rail leased in Louisiana, as of December 31, segregated by Taxing District. NAME AND ADDRESS OF LESSEE LOCATION OF LEASED RAIL NUMBER LINEAL FEET OF RAIL LEASED VALUE Railroad Report5.doc
8 6 MAIN LINE/BRANCH Under this schedule, report all property owned by your company that is not used for railroad purposes and not included in the foregoing schedules. This includes all exempt and/or non-operating property. ITEMS (SEGREGATED BY TAXING DISTRICT AND DESCRIBED IN DETAIL COST Railroad Report6.doc
9 6A RAILROAD EXEMPT PROPERTY DESCRIPTION COST NET BOOK VALUE Licensed Vehicles: Other Exemptions: TOTALS: Railroad Report6A.doc
10 7 REMARKS ENTER ANY NECESSARY EXPLAINATION OF ITEMS IN THE SCHEDULE CORRESPONDING WITH THE RESPECTIVE NUMBERS. STATE OF PARISH OF Before me, the undersigned authority, personally came and appeared, Who, being duly sworn, deposes and says that the foregoing return has been prepared under my directions, from the original books, papers and records of the taxpayer and that the figures, values and other data shown herein are complete, true and correct, according to the best of my knowledge, information and belief. Sworn to and subscribed before me this day of, 20. NAME OF OFFICER NOTARY PUBLIC Railroad Report7.doc 12/22/2017
Annual Airline/Express Report
Annual Airline/Express Report OF THE COMPANY ADDRESS FOR THE YEAR ENDING DECEMBER 31, 2007 TO THE LOUISIANA TAX COMMISSION Post Office Box 66788 Baton Rouge, LA 70896 225.925.7830 1 ANNUAL AIRLINE/EXPRESS
More informationTRANSMITTAL INFORMATION For All Business Filings
JAY DARDENNE SECRETARY OF STATE STATE OF LOUISIANA SECRETARY OF STATE Commercial (225) 925-4704 (225) 922-0435 Fax Administrative Services (225) 925-4704 (225) 925-4726 Fax Uniform Commercial Code (225)
More informationAffidavit and Revenue Certification. Martin Luther King Health Center Caddo Parish Shreveport, Louisiana
/oolo Affidavit and Revenue Certification Caddo Parish Shreveport, Louisiana ANNUAL SWORN FINANCIAL STATEMENTS AND CERTIFICATION OF REVENUES $50,000 OR LESS (if applicable) The annual sworn financial statements
More informationAffidavit and Revenue Certification. (City), Louisiana
Affidavit and Revenue Certification ENTITY NAME (City), Louisiana ANNUAL SWORN FINANCIAL STATEMENTS AND CERTIFICATION OF REVENUES $50,000 OR LESS (if applicable) j^o NOT ^r>j
More informationVILLAGE OF PIONEER, LOUISIANA
"OR 10 Financial Report As of and For the Year Ended June 30,2005 Under provisions of state law, this report is a public document. Acopy of the report has been submitted to the entity and other appropriate
More informationAffidavit and Revenue Certification. Ward One Economic Development Board ENTITY NAME Calcasieu Parish Lake Charles. Louisiana (City), State
Affidavit and Revenue Certification Ward One Economic Development Board ENTITY NAME Calcasieu Parish Lake Charles. Louisiana (City), State ANNUAL SWORN FINANCIAL STATEMENTS AND CERTIFICATION OF REVENUES
More informationAffidavit and Revenue Certification. The Salvation Army - New Orleans Area Command Orleans Parish New Orleans. LA
Affidavit and Revenue Certification Orleans Parish New Orleans. LA ANNUAL SWORN FINANCIAL STATEMENTS AND CERTIFICATION OF REVENUES $50,000 OR LESS (if applicable) The annual sworn financial statements
More informationKENNETH D. FOLDEN & Co.
Financial Statements For the Year Ended June 3 0,2007 - i r/ > Under provisions of state law, this report is a public C : document Acopy of the report has been submitted to, the entity and other appropriate
More informationBACK in FILE) CENTERVILLE VOLUNTEER FIRE COMPANY. INC. Centerville, Louisiana. Financial Statements. For the Year Ended September 30, 2004
RECEIVED.EGiSLATiVE AUDITOR 01* DEC 28 PHIZ'UT u,- BACK in FILE) CENTERVILLE VOLUNTEER FIRE COMPANY. INC. Centerville, Louisiana Financial Statements For the Year Ended September 30, 2004 Under provision^
More informationAffidavit and Revenue Certification. Avoyelles Parish. Marksville, LA (City). State
Affidavit and Revenue Certification Avoyelles Parish Marksville, LA (City). State ENTITY NAME ANNUAL SWORN FINANCIAL STATEMENTS AND CERTIFICATION OF REVENUES $75,000 OR LESS (if applicable) The annual
More informationAffidavit and Revenue Certification FRENCH QUARTER MANAGEMENT DISTRICT 1100 POYDRAS STREET SUITE 1800 NEW ORLEANS, LOUISIANA 70163
/O/i/i (D Affidavit and Revenue Certification 1100 POYDRAS STREET ANNUAL SWORN FINANCIAL STATEMENTS AND CERTIFICATION OF REVENUES $50,000 OR LESS (if applicable) The annual sworn financial statements are
More informationLOUISIANA LEGISLATIVE AUDITOR STEVE J. THERIOT, CPA. April 30,2008
LOUISIANA LEGISLATIVE AUDITOR STEVE J. THERIOT, CPA April 3,28 To whom it may concern: This report was submitted by the Department of Agriculture. It may not meet the criteria of Louisiana Revised Statutes
More informationLOUISIANA DEPARTMENT OF THE TREASURY DEPUTY SHERIFFS SUPPLEMENTAL PAY BOARD OF REVIEW
LOUISIANA DEPARTMENT OF THE TREASURY DEPUTY SHERIFFS SUPPLEMENTAL PAY BOARD OF REVIEW SHERIFFS GUIDE TO DEPARTMENTAL POLICIES AND STATUTORY SPECIFICATIONS FOR THE ADMINISTRATION OF THE SUPPLEMENTAL PAY
More informationManchac Volunteer Fire Department
ZOO] A"; 23 AHH:27 Manchac Volunteer Fire Department Annual Financial Statements As of and for the Year Ended December 31, 2006 Under provisions of state law, this report is a puolic document. Acopy of
More informationSTEVEN E. SANDERS : JUSTICE OF THE PEACE WARD 3. DISTRICT 2 BATON ROUGE, EAST BATON ROUGE PARISH, LOUISIANA ANNUAL FINANCIAL STATEMENTS
^^>V^'^ R.ECEIVED LEGISLATIVE AUDIT'IP 2013JUI1I9 AH 9-06 : WARD 3. DISTRICT 2 ANNUAL FINANCIAL STATEMENTS YEAR ENDED DECEMBER 3 L 2012 Under provisions of state law, tliis report is a public document.
More informationLASALLE SOIL & WATER CONSERVATION DISTRICT Jena, Louisiana Financial Statements June 30,2014
wn LASALLE SOIL & WATER CONSERVATION DISTRICT Jena, Louisiana Financial Statements June 30,2014 Under provisions of state law, this report is a public document A copy of the report has been submitted to
More informationVidalia, Louisiana. Annual Financial Statements and Accountants Compilation Reports. June 30,2006 and for the Year Then Ended
CONCORDIA PARISH ECONOMIC & INDUSTRIAL DEVELOPMENT DISTRICT Vidalia, Louisiana Annual Financial Statements and Accountants Compilation Reports June 30,2006 and for the Year Then Ended Under provisions
More informationLOUISIANA LEGISLATIVE AUDITOR STEVE X THERIOT, CPA. April 30,2008
LOUISIANA LEGISLATIVE AUDITOR STEVE X THERIOT, CPA April 30,2008 To whom it may concern: This report was submitted by the Department of Agriculture. It may not meet the criteria of Louisiana Revised Statutes
More informationLOUISIANA STATE BOARD OF OPTOMETRY EXAMINERS STATE OF LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS ANNUAL FINANCIAL STATEMENTS
LOUISIANA STATE BOARD OF OPTOMETRY EXAMINERS STATE OF LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS ANNUAL FINANCIAL STATEMENTS YEAR ENDED DECEMBER 31, 2007 Under provisions of state law. this report is
More informationVillage of Longstreet FINANCIAL REPORT YEAR ENDED JUNE 30, 2005
Village of Longstreet FINANCIAL REPORT YEAR ENDED JUNE 3, 25 (CPAJ The CPA. Never Underestimate The Value;'" Under provisions of state law, this report is a public document. A copy of the report has been
More informationLINCOLN PARISH WATERWORKS DISTRICT NO Barham Road Dubach, Louisiana 71235
.^^52 LINCOLN PARISH WATERWORKS DISTRICT NO. 1 141 Barham Road Dubach, Louisiana 71235 TRANSMITTAL LETTER ANNUAL FINANCIAL STATEMENTS January 26, 2011 Mr. Daryl G. Purpera, CPA Louisiana Legislative Auditor
More informationQuarter Horse Racing Assn of LA. Financial Statements. As of and for the periods ended December 31, 2009
"roy^^ Quarter Horse Racing Assn of LA Financial Statements As of and for the periods ended December 31, 2009 Under provisions of state law, this report is a public document Acopy of the report has been
More informationLOAN ORIGINATOR APPLICATION INSTRUCTIONS
LOAN ORIGINATOR APPLICATION INSTRUCTIONS Each person that meets the definition of an originator and who is not employed by a residential mortgage lender exempt under Section 1087(A), (B) or (C)(1) of the
More informationAffidavit and Revenue Certffication WAYNE L KELLY OUACHITA PARISH MONROE, LA
Affidavit and Revenue Certffication G) WAYNE L KELLY OUACHITA PARISH MONROE, LA ANNUAL SWORN FINANCIAL STATEMENTS AND CERTIFICATION OF REVENUES $75,000 OR LESS (if applicable) The annual sworn financial
More informationAPPLICATION TO TRANSFER CAPITAL CREDIT ACCOUNT OF DECEASED MEMBER
FLORIDA KEYS ELECTRIC COOPERATIVE ASSOCIATION, INC. PO BOX 377 TAVERNIER, FL 33070 (305) 852-2431 (800) 858-8845 APPLICATION TO TRANSFER CAPITAL CREDIT ACCOUNT OF DECEASED MEMBER INSTRUCTIONS: Please complete
More informationOFFICE OF DIANE TRAUTMAN
OFFICE OF DIANE TRAUTMAN COUNTY CLERK, HARRIS COUNTY, TEXAS PROBATE COURTS DEPARTMENT IN MATTERS OF PROBATE DOCKET NO. PROBATE COURT NO. STYLE OF DOCKET: HARRIS COUNTY, TEXAS DECEASED/INCAPACITATED/MINOR
More informationREQUIREMENTS FOR REGISTRATION OF SECURITIES BY COORDINATION Article 303 of the Puerto Rico Uniform Securities Act
REQUIREMENTS FOR REGISTRATION OF SECURITIES BY COORDINATION Article 303 of the Puerto Rico Uniform Securities Act Initial Filing: Form U-1 or Form S-2 Consent to Service of Process: Form U-2 or Form R-6
More informationEMPLOYER S APPPLICATION FOR RENEWAL OF EXEMPTION FROM INSURING ALL OR PART OF ITS COMPENSATION LIABILITY
STATE OF NEW JERSEY DEPARTMENT OF BANKING AND INSURANCE EMPLOYER S APPPLICATION FOR RENEWAL OF EXEMPTION FROM INSURING ALL OR PART OF ITS COMPENSATION LIABILITY Name of employer Address (As provided by
More informationIMPORTANT GENERAL INSTRUCTIONS
IMPORTANT GENERAL INSTRUCTIONS 1. Each prospective bidder is required to file a prequalification questionnaire consisting of an Experience Record, Financial Statement, and Equipment Schedule, on a form
More informationARTICLES OF INCORPORATION OF LOUISIANA ASSOCIATION OF COLLEGIATE REGISTRARS AND ADMISSIONS OFFICERS, INC. (A LOUISIANA NONPROFIT CORPORATION)
ARTICLES OF INCORPORATION OF LOUISIANA ASSOCIATION OF COLLEGIATE REGISTRARS AND ADMISSIONS OFFICERS, INC. (A LOUISIANA NONPROFIT CORPORATION) The undersigned, acting pursuant to the Nonprofit Corporation
More informationProperty Tax Form State the Year for Which You are Applying for Allocation of Value. Instructions for Application
Application for Allocation of Value for Personal Property Used in Interstate Commerce, Commercial Aircraft, Business Aircraft, Motor Vehicle(s), or Rolling Stock Not Owned or Leased by a Railroad Property
More informationIOTA LONG POINT GRAVITY DRAINAGE DISTRICT FINANCIAL STATEMENTS DECEMBER 31,2006
IOTA LONG POINT GRAVITY DRAINAGE DISTRICT FINANCIAL STATEMENTS DECEMBER 31,2006.1 nder provisions of state law, this report is a public document. Acopy of the report has been submitted to the entity and
More informationNORTH CAROLINA DEPARTMENT OF INSURANCE FINANCIAL ANALYSIS & RECEIVERSHIP DIVISION COMPANY ADMISSIONS SECTION REGISTRATION AND APPLICATION FORM
NORTH CAROLINA DEPARTMENT OF INSURANCE FINANCIAL ANALYSIS & RECEIVERSHIP DIVISION COMPANY ADMISSIONS SECTION REGISTRATION AND APPLICATION FORM I. Registration Applicant Name: Applicant mailing address:
More informationANNUAL STATEMENT FOR THE YEAR ENDED DECEMBER 31, 2010 OF THE CONDITION AND AFFAIRS OF THE ADRIATIC INS CO
PROPERTY AND CASUALTY COMPANIES - ASSOCIATION EDITION ANNUAL STATEMENT FOR THE YEAR ENDED DECEMBER 31, 2010 OF THE CONDITION AND AFFAIRS OF THE ADRIATIC INS CO NAIC Group Code 0000, 0000 NAIC Company Code
More informationWichita County Bail Bond Board Corporate Bonding License Application
Wichita County Bail Bond Board Corporate Bonding License Application COMPANY: AGENT: DATE SUBMITTED: Form Approved by Wichita County Bail Bond Board 1/20/2016 WICHITA COUNTY BAIL BOND BOARD WICHITA COUNTY
More informationSUBCONTRACTOR QUALIFICATION STATEMENT
SUBCONTRACTOR QUALIFICATION STATEMENT The information included herein shall not be disclosed outside SEDALCO and will not be duplicated, used or disclosed - in whole or in part for any purpose other than
More informationFOOD INDUSTRY SELF INSURANCE FUND
FOOD INDUSTRY SELF INSURANCE FUND OF NEW MEXICO P.O BOX 14710 ALBUQUERQUE, NM 87191-4710 (505)298-9095 1-800-28-0893 FAX (505) 298-9094 FOOD INDUSTRY SELF INSURANCE FUND ACKNOWLEDGMENT MEMBER: ADDRESS:
More informationperformed 9. For provider complaints: MC-7
performed 3. For network management: a) Demonstration of adequacy of the network for services offered in relation to population to be served consistent with standards at N.J.A.C. 11:24B-3.5 b) Demonstration
More informationFinancial Statements. St. Tammany Parish Recreation District No. 4. Lacombe, Louisiana. December 31, 2004
r RECEIVED 05MAR1L* AWll'SU Financial Statements St. Tammany Parish Recreation District No. 4 Lacombe, Louisiana December 31, 2004 Under provisions) u'&idtelaw. this report is a r"blic document. Acopy
More informationL O U I S I A N A I N S U R A N C E G U A R A N T Y A S S O C I A T I O N
L O U I S I A N A I N S U R A N C E G U A R A N T Y A S S O C I A T I O N LIGA To be completed by all persons making claims against the Louisiana Insurance Guaranty Association ( LIGA ) pursuant to the
More informationPERSONAL FINANCIAL STATEMENT OF
OF SUBMITTED FOR CONSIDERATION BY THE TARRANT COUNTY BAIL BOND BOARD (Submit most recent available financial data use page 11 to provide explanatory notes to the Personal Financial Statement) Date of Birth:
More informationCovering Calendar Year: Mailing Address: Street or P.O. Box City County State Zip code. ( )
CFC PFD Rev. 1/14 STATE OF GEORGIA PERSONAL FINANCIAL DISCLOSURE STATEMENT 200 Piedmont Avenue S.E. Suite 1402 West Tower Atlanta, GA 30334 404-463-1980 www.ethics.ga.gov Local Location Code: Original
More informationPlaquemines Parish Courthouse District State of Louisiana Parish of Plaquemines GENERAL PURPOSE FINANCIAL STATEMENTS
Plaquemines Parish Courthouse District State of Louisiana Parish of Plaquemines GENERAL PURPOSE FINANCIAL STATEMENTS As of and for the Year Ended December 31, 2005 Under provisions of state law. this report
More informationPOLITICAL PARTY QUARTERLY REPORTING FORM
To be filed with: POLITICAL PARTY QUARTERLY REPORTING FORM For assistance in completing this form contact: Mark Martin, Secretary of State Calendar Year Arkansas Ethics Commission State Capitol, Room 026
More informationDelaware Division of Corporations 401 Federal Street Suite 4 Dover, DE Phone: Fax:
Delaware Division of Corporations 401 Federal Street Suite 4 Dover, DE 19901 Phone: 302-739-3073 Fax: 302-739-3812 TRADEMARK AND/OR SERVICE MARK RENEWAL FORM Dear Sir or Madam: As requested, enclosed is
More informationMEDICAID LOUISIANA (MCDLA) PRE-ENROLLMENT INSTRUCTIONS
MEDICAID LOUISIANA (MCDLA) PRE-ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Provider s Election to Employ Electronic Data Interchange of Claims for Processing in the Louisiana Medical Assistance Program
More informationAffidavit and Revenue Certification. D.lSA^'J TJidM^o^^/n,:bs^ /^6lU0^AiJl-tAtisl tf/y^^/^k/ ENTITY NAME. ^iilj/frj Parish
^AV Affidavit and Revenue Certification D.lSA^'J TJidM^o^^/n,:bs^ /^6lU0^AiJl-tAtisl tf/y^^/^k/ ENTITY NAME ^iilj/frj Parish J}/^i/!/JjLy L/J (City). State ANNUAL SWORN FINANCIAL STATEIVIENTS AND CERTIFICATION
More informationGENERAL REQUIREMENTS YOU MUST APPLY EACH YEAR FOR TAX RELIEF! APPLICATIONS RECEIVED AFTER JULY 5, 2017 WILL NOT BE ACCEPTED OR CONSIDERED
REAL ESTATE TAX RELIEF FY 18 APPLICATION NEW APPLICANT CITY OF MANASSAS COMMISSIONER OF THE REVENUE 9027 CENTER ST STE 104 MANASSAS VA 20110 CONTACT: TERRI MARTIN (703) 257-8298 GENERAL REQUIREMENTS To
More information2017 TOWNSHIP OF GOODLAND POVERTY TAX EXEMPTION APPLICATION
2017 TOWNSHIP OF GOODLAND POVERTY TAX EXEMPTION APPLICATION The undersigned property owner and resident of Goodland Township hereby applies for a poverty exemption in whole or in part from property taxation
More informationJustice of the Peace of Ward/District First District. Financial Statements As of and for the Year Ended December 31, 2004
of Ward/District First District Ascension Parish, Louisiana Financial Statements As of and for the Year Ended December 31, 2004 Required by Louisiana Revised Statutes 24:513 and 24:514 to Be filed with
More informationOwner-Contractor Construction Agreement For Owner Controlled Insurance Program
Owner-Contractor Construction Agreement For Owner Controlled Insurance Program This agreement is entered into as of ( Effective Date ) between Lone Star College (the "College"), a public junior college
More informationAffidavit and Revenue Certification. A/1 (City), state
Affidavit and Revenue Certification > ENTITY NAME ^/exmilian Parish A/1 (City), state ANNUAL SWORN FINANCIAL STATEMENTS AND CERTiFlGATlON OF REVENUES 75,000 OR LESS (if appiicabte) The annual sworn financial
More informationIMPORTANT GENERAL INSTRUCTIONS
IMPORTANT GENERAL INSTRUCTIONS 1. Each prospective bidder is required to file a prequalification questionnaire consisting of an Experience Record, Financial Statement, and Equipment Schedule, on a form
More informationAffidavit and Revenue Certification. o o Parish U-i tnj7s4t?r\ Lfl- (City), State
Affidavit and Revenue Certification A/0irY\f r\ ^ ** c,1 L pe Un-4? r o o Parish U-i tnj7s4t?r\ Lfl- (City), State ENTITY NAME ANNUAL SWORN FINANCIAL STATEMENTS AND CERTIFICATION OF REVENUES $50,000 OR
More informationPOLICY AND GUIDELINES FOR GRANTING POVERTY EXEMPTIONS FOR THE TOWNSHIP OF THOMPSON, SCHOOLCRAFT COUNTY, STATE OF MICHIGAN
POLICY AND GUIDELINES FOR GRANTING POVERTY EXEMPTIONS FOR THE, SCHOOLCRAFT COUNTY, STATE OF MICHIGAN The homestead, also defined as principal residence exemption or qualified agriculture of persons who,
More informationChange Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account
THIS FORM MUST BE PROCESSED BY CHANGE HEALTHCARE PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy
More informationApplication and Joint Certification
DLN: Application and Joint Certification Republika ng Pilipinas Kagawaran ng Pananalapi Kawanihan ng Rentas Internas (For transfer to a controlled corporation under Section 40(C)(2) and (6)(c), Tax Code
More informationNorthern Capital Insurance Company
ANNUAL STATEMENT OF THE Northern Capital Insurance Company of Miami in the state of Florida 2009 TO THE Insurance Department OF THE STATE OF Florida For the Year Ended December 31, 2009 PROPERTY AND CASUALTY
More informationDIVISION OF BANKING 1511 Pontiac Avenue, Building 68-1 Cranston, Rhode Island Telephone (401) Facsimile (401)
DIVISION OF BANKING 1511 Pontiac Avenue, Building 68-1 Cranston, Rhode Island 02920 TO: RE: Telephone (401) 462-9503 - Facsimile (401) 462-9532 LENDER, SMALL LOAN LENDER, LOAN BROKER AND THIRD PARTY LOAN
More informationMEDICAID LOUISIANA PRE ENROLLMENT INSTRUCTIONS MCDLA
MEDICAID LOUISIANA PRE ENROLLMENT INSTRUCTIONS MCDLA HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 3 weeks. WHERE SHOULD I SEND THE FORMS? Mail the form to: Unisys Provider Enrollment
More informationAPPLICATION FOR DEALERS LICENSE
INSTRUCTIONS FOR APPLICANTS IN MAKING FIRST APPLICATION FOR DEALERS LICENSE APPLICATION MUST BE ACCOMPANIED BY ALL OF THE FOLLOWING DOCUMENTS: 1. *THE PROPOSED DEALERSHIP NAME MUST BE APPROVED BY THIS
More information*,!? - OSFEB-l. AH IMS DUACHITA PARISH. EAST TOWN a. COUNTRY DRAINAGE DISTRICT MONROE, LOUISIANA FOR THE YEAR ENDING DECEMBER 31, SOQ4-
*,!? - OSFEB-l. AH IMS I DUACHITA PARISH EAST TOWN a. COUNTRY DRAINAGE DISTRICT MONROE, LOUISIANA FOR THE YEAR ENDING DECEMBER 31, SOQ4- j'state law, this report is apublfc document, Aoopy of the report
More informationNON-PROFIT CLUB OFFICER SUBSTITUTION
THE ALCOHOL BEVERAGE BOARD OF ST. MARY S COUNTY P. O. BOX 653 41650 TUDOR HALL RD., LEONARDTOWN, MD 20650 (301) 475-7844 EXT. 1600 FAX (301) 475-3364 NON-PROFIT CLUB OFFICER SUBSTITUTION PAPERWORK DEADLINE:
More informationBIDDER S QUALIFICATION AND EXPERIENCE STATEMENT
BIDDER S QUALIFICATION AND EXPERIENCE STATEMENT The OWNER will require supporting evidence regarding Bidder s Qualifications and competency. The Bidder will be required to furnish all of the applicable
More informationTIP 95A01-28 Date Issued: Sep 28, 1995 EXEMPTION EXTENDED FOR LARGE BOATS SOLD TO NONRESIDENTS
TIP 95A01-28 Date Issued: Sep 28, 1995 EXEMPTION EXTENDED FOR LARGE BOATS SOLD TO NONRESIDENTS Effective October 1, 1995, the existing exemption for sales of boats to nonresidents has been extended to
More informationCHECKLIST OF REQUIRED ITEMS FOR LIQUOR LICENSE APPLICATIONS
Matthew Brantner Director of Liquor Control CHECKLIST OF REQUIRED ITEMS FOR LIQUOR LICENSE APPLICATIONS Completed Application Affidavit Completed Personal Information Application Competed Application for
More informationCOULEE CROCHE FIRE PROTECTION DISTRICT NO. FOUR CANKTON, LOUISIANA ANNUAL FINANCIAL REPORT FOR THE YEARS ENDED DECEMBER 31.
, r r,j^tlved LEGb,.^!'.'r A, jd)ror 05APR-I M :35 COULEE CROCHE FIRE PROTECTION DISTRICT NO. FOUR ANNUAL FINANCIAL REPORT FOR THE YEARS ENDED DECEMBER 31. 2004 AND 200, Under provisions uf stale law,
More informationContractor s Qualification Statement
THE AMERICAN INSTITUTE OF ARCHITECTS AIA Document A305 Contractor s Qualification Statement 1986 EDITION This form is approved and recommended by The American Institute of Architects (AIA) and The Associated
More informationINTERIM WAIVER AND RELEASE UPON PAYMENT. The undersigned mechanic and/or materialman has been employed by Pattillo Construction
AL Form Subcontractor INTERIM WAIVER AND RELEASE UPON PAYMENT STATE OF ALABAMA COUNTY OF The undersigned mechanic and/or materialman has been employed by Pattillo Construction Corporation to furnish for
More informationE. J. Bourgeois, Constable Jefferson Parish 6th Justice Court
E. J. Bourgeois, Constable Jefferson Parish 6th Justice Court Compiled Financial Statements and Supplementary Information William D. Mercer, CPA A PROFESSIONAL ACCOUNTING CORPORATION CONTENTS Accountant's
More informationSCHEDULE 1 Applicant Information. Federal Tax ID #: ABA #: FDIC, NCUA, NAIC or CDFI Fund Certificate #: GENERAL INFORMATION
Type of financial institution: SCHEDULE 1 Applicant Information Bank Thrift Credit Union Insurance Company Non-federally insured CDFI Legal Name of Institution: Street Address: City: State: County: Zip:
More informationASOCIACION DE SUSCRIPCION CONJUNTA DEL SEGURO DE RESPONSABILIDAD OBLIGATORIO
ANNUAL STATEMENT OF THE ASOCIACION DE SUSCRIPCION CONJUNTA DEL SEGURO DE RESPONSABILIDAD OBLIGATORIO of SAN JUAN in the state of TO THE Insurance Department OF THE STATE OF Puerto Rico For the Year Ended
More informationDIVISION OF BANKING 1511 Pontiac Avenue, Building 68-1 Cranston, Rhode Island Telephone (401) Facsimile (401)
DIVISION OF BANKING 1511 Pontiac Avenue, Building 68-1 Cranston, Rhode Island 02920 Telephone (401) 462-9503 - Facsimile (401) 462-9532 APPLICATION FOR APPROVAL TO ESTABLISH A FINANCIAL INSTITUTION PURSUANT
More informationContractor s Qualification Statement
THE AMERICAN INSTITUTE OF ARCHITECTS AIA Document A305 Contractor s Qualification Statement 1986 EDITION This form is approved and recommended by The American Institute of Architects (AIA) and The Associated
More informationThe Canada Southern Railway Company 1973 ANNUAL REPORT
The Canada Southern Railway Company 1973 ANNUAL REPORT BOARD OF DIRECTORS TO OUR SHAREHOLDERS E. L. Claypole J. T. Cooper F. J. Gasparini Perm Central Transportation Company (Penn Central) operates the
More informationINSTRUCTIONS FOR PROVIDER'S ELECTION TO EMPLOY ELECTRONIC DATA INTERCHANGE OF CLAIMS FOR PROCESSING IN THE LOUISIANA MEDICAL ASSISTANCE PROGRAM
Individual Louisiana s Medicaid Program INSTRUCTIONS FOR PROVIDER'S ELECTION TO EMPLOY ELECTRONIC DATA INTERCHANGE OF CLAIMS FOR PROCESSING IN THE LOUISIANA MEDICAL ASSISTANCE PROGRAM Prior to submitting
More informationIn-State Travel (NOTE: No receipts are used for In-State travel; only per diems are applied; See below)
Section 20 Page 1 Travel Expense Report (Yellow Form) (see exhibit B25) Mileage Mileage rate as of January 1, 2009 is $.55. This is the federal rate. The mileage rate will vary annually based on the federal
More informationGWINNETT COUNTY DEPARTMENT OF WATER RESOURCES
October 18, 2011 NOTICE OF PRE-QUALIFICATION OF CONTRACTORS FOR THE INSTALLATION, REPLACEMENT AND/OR RELOCATION OF PRESSURIZED WATER MAINS AND SEWER FORCE MAINS AND APPURTENANCES Gwinnett County is soliciting
More informationDISABLED VETERANS REAL ESTATE TAX EXEMPTION PROGRAM
DISABLED VETERANS REAL ESTATE TAX EXEMPTION PROGRAM APPLICATION FOR EXEMPTION FROM REAL PROPERTY TAXES Every blank must have an entry or the application will be returned. No determination can be made until
More informationMEDICAID LOUISIANA (MCDLA) PRE-ENROLLMENT INSTRUCTIONS
MEDICAID LOUISIANA (MCDLA) PRE-ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Provider s Election to Employ Electronic Data Interchange of Claims for Processing in the Louisiana Medical Assistance Program
More informationBRUCE TOWNSHIP MACOMB COUNTY POVERTY EXEMPTION APPLICATION TAX YEAR 2018
B.O.R. Mar Jul Dec Letter / Appt Parcel No. Name: Date: Time: Petition #: A. DEADLINE BRUCE TOWNSHIP MACOMB COUNTY POVERTY EXEMPTION APPLICATION TAX YEAR 2018 YOU MUST COMPLETE THIS APPLICATION IN FULL
More informationSOUTHERN UNIVERSITY LAW CENTER LOAN REDUCTION ASSISTANCE PROGRAM 2 Roosevelt Steptoe Dive or Post Office Box 9294 Baton Rouge, Louisiana 70813
SOUTHERN UNIVERSITY LAW CENTER LOAN REDUCTION ASSISTANCE PROGRAM 2 Roosevelt Steptoe Dive or Post Office Box 9294 Baton Rouge, Louisiana 70813 APPLICATION FORM Deadline: August 15 (or the next business
More informationTITLE CLOSER AFFIDAVIT TRUST
TITLE CLOSER AFFIDAVIT TRUST AFFIDAVIT OF TRUST AND INDEMNITY STATE OF NEW YORK ) TITLE NO.: County of ) I/We hereby certify to TitleSave Agency, Inc (the Title Agency ) and Chicago Tile Insurance Company
More informationPlaquemines Parish Courthouse District State of Louisiana Parish of Plaquemines
Plaquemines Parish Courthouse District State of Louisiana Parish of Plaquemines GENERAL PURPOSE FINANCIAL STATEMENTS As of and for the Year Ended December 31,2004 Under provisions of state law, this report
More informationGood Will Institute for Health Services Slidell, LA DECEMBER 31,
/O/,^ Slidell, LA FINANCIAL STATEMENTS DECEMBER 31, 200B Under provisions of state law, this report is a public document. Acopy of the report has been submitted to the entity and other appropriate public
More information* * PROPERTY AND CASUALTY COMPANIES ASSOCIATION EDITION
*45680600000* PROPERTY AND CASUALTY COMPANIES ASSOCIATION EDITION ANNUAL STATEMENT For the Year Ended December, 06 OF THE CONDITION AND AFFAIRS OF THE Maison Insurance Company NAIC Group Code 06, 06 NAIC
More informationSTATEMENT OF BIDDER S QUALIFICATIONS (GENERAL CONTRACTOR)
HOUSING AUTHORITY OF THE COUNTY OF SAN BERNARDINO CAPITAL FUND PROGRAM 715 E. BRIER DRIVE SAN BERNARDINO, CA 92408-2841 (909) 890-0644 FAX (909) 915-1831 STATEMENT OF BIDDER S QUALIFICATIONS (GENERAL CONTRACTOR)
More informationLOUISIANA MEDICAID CONTRACT INSTRUCTIONS (SKLA0)
LOUISIANA MEDICAID CONTRACT INSTRUCTIONS (SKLA0) Please MAIL all pages of the completed and signed agreement to: ABILITY One Metro Center 4010 Boy Scout Blvd Suite 900 Tampa, FL 33607 INSTRUCTIONS Do not
More informationLOUISIANA BOARD OF WHOLESALE DRUG DISTRIBUTORS DEPARTMENT OF HEALTH AND HOSPITALS STATE OF LOUISIANA BASIC FINANCIAL STATEMENTS
DEPARTMENT OF HEALTH AND HOSPITALS STATE OF LOUISIANA BASIC FINANCIAL STATEMENTS AS OF AND FOR THE YEAR ENDED JUNE 30,2007 Under provisions of state law. this report is a public document Acopy of the report
More informationHow to Give Your Kavilco Shares
How to Give Your Kavilco Shares The Alaska Native Claims Settlement Act (43 U.S.C. Subsection 1606) permits a shareholder to give a gift of shares to his or her child, grandchild, great grandchild, niece,
More informationUNION PACIFIC CORPORATION
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 8-K CURRENT REPORT Pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934 Date of Report (Date of earliest event
More informationEMPLOYEES OWNED SPECIAL CORPORATION INFORMATIVE TAX RETURN
Form 480.20(CPT) Rev. 03.99 Reviewer: Liquidator: Field audited by: Date / / R M N Entity's Name Year COMMONWEALTH OF PUERTO RICO DEPARTMENT OF THE TREASURY Year EMPLOYEES OWNED SPECIAL CORPORATION INFORMATIVE
More informationNATCHITOCHES TAX COMMISSION NATCHITOCHES, LOUISIANA FINANCIAL STATEMENTS FOR THE YEAR ENDED JUNE 30, 2004
NATCHITOCHES, LOUISIANA FINANCIAL STATEMENTS FOR THE YEAR ENDED JUNE 30, 2004 Under provisions of state law. this report is a public document. Aco py of the report has been submitted to the entity and
More informationREINSURANCE COMPANY FORMATION Checklist and Instructions. FOR USE WITH CONTROLLED FOREIGN CORPORATIONS ( CFCs ) ONLY
REINSURANCE COMPANY FORMATION Checklist and Instructions FOR USE WITH CONTROLLED FOREIGN CORPORATIONS ( CFCs ) ONLY Receipt of the following items is required before we may submit any Company to the Turks
More informationLAKE CHARLES HARBOR AND TERMINAL DISTRICT TUG BOAT PERMIT PROCEDURES
LAKE CHARLES HARBOR AND TERMINAL DISTRICT TUG BOAT PERMIT PROCEDURES Tug Boat companies desiring to provide tug services to vessels utilizing the public wharves must file an application along with a check
More informationREINSTATEMENT DIRECTIONS DOMESTIC CORPORATIONS NONPROFIT CORPORATIONS LIMITED LIABILITY COMPANIES
REINSTATEMENT DIRECTIONS DOMESTIC CORPORATIONS NONPROFIT CORPORATIONS LIMITED LIABILITY COMPANIES The following steps must be taken to reinstate your corporation or limited liability company when it has
More informationANNUAL STATEMENT OF THE AMERICAN STATES PREFERRED INSURANCE COMPANY TO THE. Insurance Department OF THE FOR THE YEAR ENDED.
ANNUAL STATEMENT OF THE AMERICAN STATES PREFERRED of in the state of INDIANAPOLIS INDIANA TO THE Insurance Department OF THE FOR THE YEAR ENDED December 31, 2011 PROPERTY AND CASUALTY 2011 PROPERTY AND
More informationLOUISIANA REAL ESTATE COMMISSION Office of the Governor State of Louisiana Baton Rouge, Louisiana
LOUISIANA REAL ESTATE COMMISSION Office of the Governor State of Louisiana Baton Rouge, Louisiana Audited Financial Statements As of and For the Year Ended June 30, 2005 Under provisions of state law,
More informationANNUAL STATEMENT OF THE EMPLOYERS INSURANCE COMPANY OF WAUSAU TO THE. Insurance Department OF THE FOR THE YEAR ENDED.
ANNUAL STATEMENT OF THE EMPLOYERS OF WAUSAU of in the state of WAUSAU WISCONSIN TO THE Insurance Department OF THE FOR THE YEAR ENDED December 31, 2016 PROPERTY AND CASUALTY 2016 PROPERTY AND CASUALTY
More informationSolar Act Subsection t N.J.S.A. 48:3-87(t) Post-Construction NJDEP Compliance Form
Solar Act Subsection t N.J.S.A. 48:3-87(t) Post-Construction NJDEP Compliance Form Introduction In accordance with the Order of the Board of Public Utilities ( BPU ) dated January 23, 2013, Docket No.
More information