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Increase in Rates Application Form

NWRB application form for increase in rates

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
NATIONAL WATER RESOURCES BOARD
APPLICATION FOR INCREASE OF RATES
8th Floor, NIA Building, EDSA, Quezon City
Telefax : 920-27-14
CASE NO.
PLEASE ACCOMPLISH THIS FORM IN SIX (6) COPIES
NAME OF APPLICANT

MAILING ADDRESS

WATER PERMIT NO.
SOURCE

CONTACT NO.

LOCATION
CITIZENSHIP
SERVICE AREA
Subdivision :

TIN

DATE OF OPERATION
Existing CPC/N No., if for renewal

a. Amount ____________
b. O. R. No. ___________
c. Date ________________

Barangay :
Municipality :

Provisional Authority Required
Yes

No
NO. OF CONNECTIONS
a. with water meters _____________________
b. w/o water meters ______________________
c. meter tested ____________________
c.1 tested by ____________________
c.2 date tested ____________________
d. for bulk seller /peddler
Average volume of water delivered in cubic meters per day
________________________

TYPE OF UTILITY
[ ] Subdivision / HOA
[ ] Rural Water & Sanitation Association
[ ] Cooperative
[ ] Bulk Water Seller/Peddler
[ ] Others ________________________
(specify)

KIND OF WATER SYSTEM
[ ] Draw & Fill

FILLING FEE

[ ] Float

[ ] Direct Pumping

LIST OF DOCUMENTARY REQUIREMENTS

( )

( )
( )
( )

( )

NOTE: USE 5- YEAR TARIFF MODEL TO COMPLY ON
FINANCIAL REQUIREMENTS
Board resolution (for corporations and partnerships) or ( ) Latest Audited Financial Statements ¹
special power of attorney (for single proprietorships) ( ) Actual Balance Sheet for Water Operations ¹
( ) Actual Income Statement for Water Operations ¹
authorizing the signatory to sign and file the application
( ) List of Existing Assets in Service Subject to Return ¹
Copy of Approved Water Permit/s
Itemized Projected Financial Statements for Water
Copy of Official Receipt/s of Annual Water Charges &
Operations for 5 years
Supervision & Regulation Fee
( ) Income Statements
Copy of Latest Certificate of Potability issued by
( ) Funds Flow
City/Municipal Health Officer where source is located
( ) Balance Sheet
with Results of Bacteriological, Physical & Chemical
( ) Assumptions
Copy of Latest Annual Report
( ) Comparative statements showing revenue based on the
present authorized rates and on the proposed increased of
rates
( ) Business Plan & Itemized List of Required Investments
for the Next 5 yrs.
( ) Proposed Tariff Schedule
( ) Levels of service agreed with consumers commensurate
with proposed rates
( ) Others
1

If applicant has another operations other than water supply

I HEREBY CERTIFY THAT THE INFORMATION
GIVEN ABOVE AND THE DOCUMENTS SUBMITTED
ARE TRUE AND CORRECT TO THE BEST OF
KNOWLEDGE AND BELIEF

SUBSCRIBED AND SWORN TO BEFORE ME ON THIS
DATE

Signature of Water Utility Representative

Notary Public / Administering Officer
 
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