Registration for Private, Nonprofit Land-Holding Organization to Receive Notice of Water Company Plans to Sell Land or Change Water Supply Plans

Use this form to register a private, nonprofit land-holding organization with the Public Utilities Regulatory Authority (PURA) for the purpose of receiving notice of the sale, lease or other disposition of water company land or notice of a change in a water supply plan in accordance with sections 25-32d(d) and 16-150c(b) of the Connecticut General Statutes (CGS).

Part I: Private, Nonprofit Land Holding Organization Information

Name of Organization:
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext.:
Contact Person: Phone:
*Email:
*By providing this e-mail address you are agreeing to receive official correspondence from PURA, at this electronic address, concerning the subject application. Please remember to check your security settings to be sure you can receive e-mails from “ct.gov” addresses. Also, please notify PURA if your e-mail address changes.

Part II: Municipality(s) where Organization Owns Land and Adjacent Municipalities

List the Connecticut municipality(s) in which the organization, specified in Part I of this form, owns land and the municipalities adjacent to such municipality(s).

Municipality / Adjacent Municipalities

DEEP-PURA-REG-001 Page 1 of 2 Rev. 11/27/2017

Part II: Municipality(s) where Organization Owns Land and Adjacent Municipalities (continued)

Municipality / Adjacent Municipalities
Check here if additional sheets are necessary, and label and attach them to this sheet.

Part III: Registrant Certification

“I have personally examined and am familiar with the information submitted in this document, and I certify that based on reasonable investigation, including inquiry of the individuals responsible for obtaining the information, the submitted information is true, accurate and complete to the best of my knowledge and belief.
I understand that a false statement in the submitted information may be punishable as a criminal offense, in accordance with section 22a-6 of the Connecticut General Statutes, pursuant to section 53a-157b of the Connecticut General Statutes, and in accordance with any other applicable statute.”
“By entering my name below, I agree that I am providing my legal signature, and am legally bound by the certifications above.”
/s/
Signature of Authorized Representative
(President or Secretary) / Date
Printed Name of Authorized Representative / Title

To submit this form electronically, save the completed form as a pdf/A and send to

Otherwise, please submit this completed Registration Form to:

EXECUTIVE SECRETARY
PUBLIC UTILITIES REGULATORY AUTHORITY
DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION
TEN FRANKLIN SQUARE
NEW BRITAIN, CT 06051

For filing questions, contact the Executive Secretary by email at or by phone at 860-827-1553.

DEEP-PURA-REG-001 Page 1 of 2 Rev. 11/27/2017