Form EIA-871C Natural Gas Usage

2012 Commercial Buildings Energy Consumption Survey (CBECS)

Sponsored by the Energy Information Administration

U.S. Department of Energy

Washington, DC 20585

Case Label Here

Natural Gas Usage Form

(Form EIA-871C)

Form approval
OMB No.: 1905-0145

Expires: xx/xx/xxxx

Look at the label and indicate the type of unit for which you are instructed to provide information:

 Entire building

 Establishment or business within the building

In the following questions, the entire building or establishment within the building will be referred to as the reporting unit.

Complete this form and return it by xx xx, xxxx. Reporting is mandatory under Public Law 93-275, as amended. If you have any questions, please call (toll-free) 1-888-xxx-xxxx and ask for [CONTRACTOR].

Title 18 U.S.C. 1001 makes it a criminal offense for any person knowingly and willingly to make to any Agency or Department of the United States any false, fictitious, or fraudulent statements as to any matter within its jurisdiction.

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time of reviewing instructions, searching existing data records, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Energy Information Administration, Office of Survey Development and Statistical Integration, EI-21, Washington, DC 20585-0670, and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.

C ONTACT INFORMATION

Please provide the following information for the person who completed this form.
(Use each box for individual letters, numbers, characters, or spaces. Please print in CAPS.)

Name: 

Job Title: 

Company: 

E-Mail Prefix: 

E-Mail Domain: 

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Example:

Telephone: 

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Fax Number: 

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G ENERAL INSTRUCTIONS

Reporting format: Report the requested information on this form or in a format that is convenient for you, such as a computer printout. Make sure the alternate format includes the required information. Examples of completed forms and Frequently Asked Questions are available on the Energy Information Administration website at: http://www.eia.gov/consumption/commercial/ess

Privacy of account numbers: We identify buildings only by the CBECS building identification number, shown on the label on the first page; we do not need your individual account numbers. If you have privacy concerns for your customers, please mark out or omit your own account numbers from any submissions. However, make sure you write the CBECS building identification number on any forms or printouts you send us.

Multiple accounts: Submit a single report for the entire reporting unit summing across all accounts. The total should include former customers who occupied the space during the reporting period. If it is easier, you may provide a separate report for each of the accounts and we will aggregate the data for you.

Reporting Period: Please report natural gas data for all of 2012. We ask for the 16 month period that begins with November 2011 and ends with February 2013; this ensures your report covers the entire calendar year plus two months before and after.

For each month (service period) provide the following for the reporting unit:

1. End date (month/day/year)

2. Natural gas quantities

3. Natural gas charges

If you…	Deliver and sell, or deliver only, natural gas directly to the reporting unit (e.g. your company is the local natural gas utility)		Worksheet 1 for quantities and all charges (dollars)
If you…	Sell only, natural gas to the reporting unit, (e.g. your company is a third-party natural gas supplier or marketer)		Worksheet 2 for quantities and sales charges only (dollars)

Worksheet 1—Natural Gas Deliveries, Calendar Year 2012

Service Period	End Date (first period should include 11/2011)						Amount of Natural Gas Delivered										Total Costs
#	MM		DD		YY		(enter only numeric values and indicate units below)										U.S. Dollars ($) and Cents (¢) (enter only numeric values)
1															.										.
2															.										.
3															.										.
4															.										.
5															.										.
6															.										.
7															.										.
8															.										.
9															.										.
10															.										.
11															.										.
12															.										.
13															.										.
14															.										.
15															.										.
16															.										.
What units did you report the natural gas units in? (mark with “x”)										What costs are included? (mark with “x” all that apply) Exclude merchandise and repair costs; hookup, disconnect, and late payment fees.
 Therms (thm)										 Commodity charges								 State and local taxes and surcharges
 Cubic Feet (cf)										 Delivery charges								 Management, storage, handling, or broker fees
 100 Cubic Feet (Ccf)										 Demand charges								 Other, specify ___________________________________________________
 1,000 Cubic Feet (Mcf)										 Fuel adjustment charges								______________________________________
 Dekatherms (Dth)										 System charges (minimum bill/base charge)
 Other units, specify ______________________________________________________________

Worksheet 2 — Natural Gas Sales, Calendar Year 2012

Service Period	End Date (first period should include 11/2011)						Amount of Natural Gas Sold										Total Costs
#	MM		DD		YY		(enter only numeric values and indicate units below)										U.S. Dollars ($) and Cents (¢) (enter only numeric values)
1														.										.
2														.										.
3														.										.
4														.										.
5														.										.
6														.										.
7														.										.
8														.										.
9														.										.
10														.										.
11														.										.
12														.										.
13														.										.
14														.										.
15														.										.
16														.										.
What units did you report the natural gas units in? (mark with “x”)									What costs are included? (mark with “x” all that apply) Exclude merchandise and repair costs; hookup, disconnect, and late payment fees.
 Therms (thm)									 Commodity charges						 State and local taxes and surcharges
 Cubic Feet (cf)									 Demand charges						 Management, storage, handling, or broker fees
 100 Cubic Feet (Ccf)									 Fuel adjustment charges						 Other, specify ___________________________________________________
 1,000 Cubic Feet (Mcf)									 System charges (minimum bill/base charge)						______________________________________
 Dekatherms (Dth)
 Other units, specify ______________________________________

7

Coverage, classification, AND PROGRAM information:

1 . Do the responses in Worksheet 1 and/or 2 include all active accounts or customers in this reporting unit as of December 31, 2011?

 Yes

 No

 Don’t Know

2. Does the information reported in Worksheet 1 and/or 2 include deliveries or sales to any other building(s) or unit(s) other than the reporting unit?

 Yes  The information includes substantial deliveries or sales to buildings or units other than the reporting unit and you were unable to report separately for the reporting unit.

 No  The information includes deliveries or sales to only the reporting unit (or the reporting unit and minor out-buildings, such as a shed).

 Don’t know

3. How do you classify the reporting unit in your records?

 Commercial

 Residential

 Industrial

 Commercial/Industrial

 Other, specify _______________________

4. Are the customers in this reporting unit eligible to participate in a “customer choice” program, that is, are they allowed to purchase fuel from an alternative supplier?

 Yes

 No

 Don’t Know

Return your Completed Questionnaire(s):

Please use the enclosed FedEx label and envelope to return the questionnaire(s) to:		United States Department of Energy c/o [CONTRACTOR] STREET. CITY, STATE ZIPCD-PLUS
Or you may FAX a copy of the completed form to [CONTRACTOR] at:		1-800-xxx-xxxx

Thank you for completing this form.