Section 170IAC8.5-3-3. Sample CTA application and personal guarantee forms

   (a) The application form is as follows:

STATE OF INDIANA
UTILITY REGULATORY COMMISSION
APPLICATION OF _________________________________________	)
FOR A CERTIFICATE OF TERRITORIAL	)
AUTHORITY TO RENDER SEWAGE DISPOSAL	) CAUSE NO.
SERVICE IN A RURAL AREA IN _______________________________	)
COUNTY, INDIANA.	)
TO THE INDIANA UTILITY REGULATORY COMMISSION:

  Your applicant, _______________________________________________respectfully represents:

  1. Applicant is a corporation organized under the laws of the State of ____________________, with its principal office in the City of ___________________, County of ____________________________. (See Note 1) The officers executing this application are authorized to receive notices and communications from the Commission. Applicant has a charter power and authority to engage in and is engaged in operating a sewage disposal service within the rural area of the State of Indiana.

  2. Applicant desires to commence rendering sewage disposal service in a rural area in ___________ County in Indiana, which rural area is shown on the Map that is marked "Exhibit A" (See Note 2), is attached hereto and is hereby made a part thereof, and which rural area is more particularly described in Item 2 of the Statement which marked "Exhibit B" (See Note 2), is attached hereto and is hereby made a part hereof. Such facilities, or extension of facilities, to provide said service as will be presently constructed, and the location thereof, are described in Item 3 of said "Exhibit B".

  3. Applicant represents that it has lawful power and authority to obtain a Certificate of Territorial Authority and to render the proposed sewage disposal service if it obtains a Certificate of Territorial Authority therefor, that it has the financial ability to provide the proposed sewage disposal service, that public convenience and necessity require the rendering of the proposed sewage disposal service, and that the public interest will be served by the issuance to applicant of the Certificate of Territorial Authority hereby sought.

  WHEREFORE, Applicant prays that, after due notice and public hearing, the Commission shall grant this application and issue to Applicant a Certificate of Territorial Authority to commence and render a sewage disposal service in the rural area herein described, and shall grant all other proper relief.

		_______________________________________________
		Name of Applicant
		By __________________________________________
		President or
		Vice-President
		(See Note 3.)
		_______________________________________________
		(Address of Applicant)
ATTEST:
_______________________________________________
SECRETARY (See Note 3.)
_______________________________________________
_______________________________________________
(Name and address of Attorney)
STATE OF ________________________________		)
		) SS:
COUNTY OF ______________________________		)
__________________, being first duly sworn on oath deposes and says that he or she is ______________________ of _________________________________, Applicant herein; that he or she has read the foregoing application and is familiar with the contents thereof; and that the statements therein contained are true to the best of his or her knowledge, information and belief.
		_______________________________________________
		(See Note 3.)
SUBSCRIBED and SWORN to before me this ____________________________________________ day of __________________________, 20 _____.
(See Note 3.) Notary Public
My Commission expires ____________________________
NOTES:
	1. If applicant is not a corporation, appropriate changes in the application, including the signature thereto, should be made.
	2. If rural areas in more than one county are covered by the application, designate "Exhibit A–Part," etc., or "Exhibit B–Part 1," etc., as applicable.
	3. Immediately below each signature the name of the person signing shall be typed in.

  (b) The personal guarantee form is as follows:

PERSONAL GUARANTEE

APPLICANT'S EXHIBIT __________

PERSONAL GUARANTEE OF ____________*

  WHEREAS, the undersigned, _____________ * is the ______________ * of ______________, *** and

  WHEREAS, he or she is also an officer of _____________** which is the owner of all the outstanding capital stock of ____________________ *** and,

  WHEREAS, he or she also owns controlling interest in the outstanding stock of _______________________**.

  NOW THEREFORE, for the purpose of inducing the Indiana Utility Regulatory Commission to issue a Certificate of Territorial Authority to ____________***, an Indiana corporation, authorizing it to furnish sewage treatment and disposal services in the area described in said Petition, the undersigned does hereby agree and bind himself or herself as follows, to wit:

  (1) To operate and maintain the plant and property of the Petitioner, ________________________*** in a satisfactory and reasonable manner so as to serve its customers with adequate service as authorized and directed by the Indiana Utility Regulatory Commission.

  (2) To supply, from time to time, sufficient working capital to said Petitioner corporation if and when such capital shall be needed to carry out the guarantee herein set forth.

  (3) This agreement shall be in full force and effect and binding upon the undersigned ____________* for a period beginning on the date service is first rendered or the issuance of the above described Certificate of the Indiana Utility Regulatory Commission, whichever is greater, and shall continue in full force and effect for a period of five (5) years hereafter, after which said agreement shall become null and void.

  IN WITNESS WHEREOF, the said ________________* has hereunto set his or her hand and seal this _________ day of ____________, 20 ______________.

	____________________________________
STATE OF INDIANA	)
	) SS:
COUNTY OF	)

  Before me, the undersigned, a Notary Public, personally appeared ____________________* and acknowledged the execution of the above and foregoing guarantee for the use and purposes therein set forth this ___________ day of ___________, 20 ________.

	_____________________________________
	Notary Public
My Commission Expires:
_____________________________________________

  *Name and position of an officer of corporation making this guarantee.

  **Name of organization sponsoring the development requiring sewage disposal service.

  ***Name of sewage disposal services corporation.

(Indiana Utility Regulatory Commission; Service for Utilities Rendering Sewage Disposal Service in Ind; Rule 19; filed Dec 9, 1981, 10:20 a.m.: 5 IR 22; readopted filed Jul 11, 2001, 4:30 p.m.: 24 IR 4233; readopted filed Apr 24, 2007, 8:21 a.m.: 20070509-IR-170070147RFA; filed Sep 13, 2007, 1:58 p.m.: 20071010-IR-170070235FRA; readopted filed Aug 2, 2013, 2:16 p.m.: 20130828-IR-170130227RFA)