ࡱ> Z\Ya $bjbjڥڥ .TR\R\ + ttttt8&."=&?&?&?&?&?&?&$'*c&tc&ttx&eeeRtt=&e=&eei$%4Z^5%)&&0&O%b"+e"+4%"+t%xec&c&e&"+ > :: NORTH CAROLINA UTILITIES COMMISSION FILING REQUIRED PURSUANT TO COMMISSION RULE R19-1 ANNUAL REPORT OF INVESTMENTS OF _______________________________, AN ELECTRIC MEMBERSHIP CORPORATION, IN REPORTABLE SEPARATE BUSINESS ENTITIES EMC Certificate No. ______________ Twelve months ended __________________ ________________________________________ Address ________________________________________ City State Zip Code ________________________________________ Phone Number _________________________________________ Name of Contact Person __________________________________________ Phone Number __________________________________________ Email Address __________________________________________ Date of Report Please Return an Original and Six Copies To: Chief Clerks Office N. C. Utilities Commission 4325 Mail Service Center Raleigh, NC 27699-4300 PART 1: SUMMARY OF INVESTMENTS IN REPORTABLE SEPARATE BUSINESS ENTITY ACTIVITIES Subpart 1(a): Information Regarding Reportable Separate Business Entities (RSBE) In Which EMC Has an Ownership Interest Please provide the following information for each reportable separate business entity in which the EMC has an ownership interest. Attach additional pages if necessary. Name of Reportable Separate Business Entity (RSBE)Dollar Amount of EMC Equity/Ownership InvestmentIdentification of EMC Role in RSBE as Active or Passive Percentage of EMC Ownership of RSBETotal Subpart 1(b): Reconciliation of Subpart 1(a) to Audited Financial Statements Please provide the following information for the EMC. 1. Total on L18 in Subpart 1(a)2.Investment in Subsidiaries per audited financial statements filed pursuant to Rule R19-13.Difference (L1 L2) If line 3 is not zero, please explain in detail the differences in the amounts reported on line 1 and Line 2.  Part 2: VERIFICATION UNDER OATH REGARDING ACCURACY OF REPORT (NOTE: THIS VERIFICATION SHALL BE COMPLETED BY EITHER THE CHIEF EXECUTIVE OFFICER, A SENIOR LEVEL FINANCIAL OFFICER, OR THE RESPONSIBLE ACCOUNTING OFFICER.) I, __________________________________________, state and attest that the attached Annual Report of Investments in Reportable Separate Business Entities is filed on behalf of ____________________________________________________ (Name of Electric Membership Corporation) as required by the North Carolina Utilities Commission; that I have reviewed said Report and, in the exercise of due diligence, have made reasonable inquiry into the accuracy of the information provided therein; and that, to the best of my knowledge, information, and belief, all of the information contained therein is accurate and true, no material information or fact has been knowingly omitted or misstated therein, and all of the information contained in said Report has been prepared and presented in accordance with all applicable North Carolina General Statutes, Commission Rules, and Commission Orders. ____________________________________ Signature of Person Making Verification ____________________________________ Job Title ____________________________________ Date Subscribed and sworn before me this the ________________________ day of ___________________________, 20__. ____________________________________ Notary Public My Commission Expires: ______________     PAGE  PAGE 3 $%WYjv! 4 6 _ g  M e  1 2 w   : E ` a b g y z 赺走蠗hQS5CJ \hX65CJ \h35CJ \hf5CJ \ h35CJ h^C5 hf5 hf5CJh35CJ\hf5CJ\h<5CJ\ h h}CJ hfCJhf hf5CJ hf5CJ hfCJ$2$%AWXYz  5 6 _ g h  ! 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