Monthly Surcharge Collection Report Form
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1GEORGIA TELECOMMUNICATIONS RELAY SERVICE (TRS)
(Formerly Dual Party Relay Service)
MONTHLY SURCHARGE COLLECTION REPORT
From: (Company)
For Calendar Month of:
___________________________________________________
________________________________
Prepared By: ______________________________________
Phone: _________________________
1.
Our company is (select one): ILEC/CLEC ___________________________________________________
2.
For CLECs: Our company is (select one): Facilities-Based/Resale/Both __________________________
3.
Billing: We (select one) do/do not perform our own billing _____________________________________
4.
If billing done by someone else, list _________________________________________________________
5.
The TRS surcharge is listed as a line item on each subscriber’s bill (yes/no) _______________________
6.
Our company collects the TRS surcharge (yes/no) _____________________________________________
7.
Payment of TRS surcharge (select one): our company/ _____________________________pays the TRS
Surcharge into the TRS Fund.
8.
Our company uses the following method of TRS surcharge payment (select one): wire transfer/check
Date Surcharge Remitted to Fund Administrator: ____________________________________________________
Number of Access Lines Billed: ____________________________________________________________________
1.
Total Surcharge Billed
$_______________________________
2.
Total Surcharge Collected (total less uncollectables)
$_______________________________
3.
Less 2% for Administrative Billing Inquiry Expense
$_______________________________
4.
Plus Interest Earned on Collected Surcharges
+______________________________
5.
Total amount Remitted to Fund Administrator
$_______________________________
Attach as an addendum the accounting treatment of the telephone relay service fund within your local exchange
including account number, title, and a listing of all monthly accounting transactions within that account.
Please send this Statement and Addendum every month to:
Mr. Michael Russell
Primary TRS Fund Contact
Georgia Public Service Commission
244 Washington Street, SW
Atlanta, Georgia 30334-5701
Circle Method Used: A or B
A.
Wire Funds to:
Receiving Bank ABA: 061000227
Receiving Bank Name: Wachovia Bank, N.A.
Receiving Account Name: GPSC TRS Fund
Receiving Account Number: 2000133843750
B.
Make Check Payable to:
GPSC TRS Fund
Mail First Class to:
P. O. Box 101378
Atlanta, Georgia 30392-1378
Mail Overnight Mail to:
Wachovia Operational Services
Attn: GPSC TRS Fund Lockbox 101378
3585 Atlanta Avenue
Hapeville, Georgia 30354
Revised 4/2003
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