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Renewal for CPC

NWRB renewal application form of CPC with increase of rates

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APPLICATION FOR RENEWAL OF CPC WITH
NATIONAL WATER RESOURCES BOARD 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

WATER PERMIT NO.

MAILING ADDRESS

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

TYPE
[
[
[
[
[

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

KIND OF WATER SYSTEM
[ ] Draw & Fill

FILLNG FEE

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
________________________

[ ] Float

[ ] Direct Pumping

LIST OF DOCUMENTARY REQUIREM ENTS

( )
( )

( )
( )
( )

( )
( )
( )
( )

Articles of Incorporation/Partnership/ DTI Registration
Board resolution (for corporations and partnerships) or
special power of attorney (for single proprietorships)
authorizing the signatory to sign and file the application
Copy of Approved Water Permit/s
Copy of Official Receipt/s of Annual Water Charges &
Supervision & Regulation Fee
Copy of Latest Certificate of Potability issued by
City/Municipal Health Officer where source is located
with Results of Bacteriological, Physical & Chemical
Copy of Latest Annual Report
Plan of Water Distribution System
Plan,
Elevation
of
Cross-sectional Views
of
Tank/Reservoir
Plan, Elevation of Cross-sectional Views of Pump House,
Machinery & Equipment

NOTE: USE 5- YEAR TARIFF MODEL TO COMPLY ON
FINANCIAL REQUIREMENTS
( ) Latest Audited Financial Statements ¹
( ) Actual Balance Sheet for Water Operations ¹
( ) Actual Income Statement for Water Operations ¹
( ) List of Existing Assets in Service Subject to Return ¹
Itemized Projected Financial Statements for Water
Operations for 5 years
( ) Income Statements
( ) Funds Flow
( ) Balance Sheet
( ) Assumptions
( ) 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

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

Signature of Water Utility Representative

If applicant has another operations other than water supply

SUBSCRIBED AND SWORN TO BEFORE ME ON THIS DATE

Notary Public / Administering Officer
 
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