Utilities (Network Facilities Tax) Annual Lodgment Form
NOTE 	This form and any remittance should be forwarded to the Commissioner for ACT Revenue, PO Box 293, Civic Square ACT 2608 by 30 May 2009
Client Reference Number	     	

Company Name	     	ABN       	
Postal Address	     	Postcode       	
Name of Contact Person	     	Tel No       	
Email Address	     	

1.  Has the Commissioner approved a methodology for calculating your total route length?	Yes    No  
If NO, attach documentation on the methodology for determining your total network route length in kilometres	

2.  Indicate the calculation of your tax liability for each utility type	
	Determined Rate		Route Length		Tax Payable	
Electricity Transmission Network	$697	X	km	=		
						
Electricity Distribution Network	$697	X	km	=		
						
Telecommunications Network	$697	X	km	=		
						
Water Network	$697	X	km	=		
						
Gas Transmission Network	$697	X	km	=		
						
Gas Distribution Network	$697	X	km	=		
						
Sewerage Network	$697	X	km	=		
						
Other Network prescribed by regulation	$697	X	km	=		
	TOTAL TAX	=		

PRIVACY STATEMENT
All information collected by the ACT Revenue Office is protected by secrecy provisions in Acts administered by the Office and only used for the purposes of those Acts. In addition, personal information provided to the ACT Revenue Office is protected by the Privacy Act 1988 (Commonwealth).  Information (including personal information) is not disclosed to any third party unless authorised by law or with the consent of the person involved.

DECLARATION
I…………………………………………………...................................................................................... 
of ……………………………………………………………………………………………………………………,
declare that by signing this form I am declaring that all of the information in this form including any attachments is true and correct, and to the best of my knowledge, no information relevant to the consideration of my declaration has been omitted.
I understand that giving false or misleading information is a serious offence under the Criminal Code 2002.
I also acknowledge that I have read and understand the Privacy Statement.	
Signature:	Date:       	

GIVING FALSE OR MISLEADING INFORMATION IS A SERIOUS OFFENCE (section 338 Criminal Code 2002)