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Deminimus Payment Exemption Request Form - Puerto Rico Universal Service Fund Fy 2004-2005

PUERTO RICO UNIVERSAL SERVICE FUND

Deminimus Payment Exemption Request

FY 2004-2005

This form may be submitted to request Deminimus Exemption from reporting to the Puerto Rico Universal Service Fund

(PRUSF), in accordance with the Puerto Rico Universal Service Regulations Paragraph (27). Please use this form to

calculate and to notify the PRUSF Administrator that you fall within the Deminimus Exemption range of an annual

remittance less than $1,000.

Company Code: PR- ___________ Company Name: ______________________________________

Street Address: ____________________________________________________________________

City/State/Zip: ____________________________________________________________________

Filing Instructions

Line 1 -Enter total projected revenues for July 2003–June 2004 as reported on the 2003/2004 Carrier Remittance Worksheet.

Line 2 -The PRUSF Assessment Rate is calculated at 0.44% (0.0044) for the revenue data months of July 2003 - June 2004.

Line 3 -Multiply the amount on Line 1 by the amount on Line 2 and enter the result on Line 3.

1. Projected Fiscal Period Revenues: (July 2004 - June 2005)………. 1.

2. 2002-2003 PRUSF Assessment Rate: (July 2004 – June 2005)…….

0.0022

3. Total Projected Remittance: (July 2004 – June 2005) …………….. 3.

If the amount entered on Line 10 is $1,000 or less, you may qualify for a Deminimus Exemption from the PRUSF for the Fiscal Year

(July 2003 – June 2004). At the end of the Fiscal Year, you will be required to true up your projection to actuals, to ensure you qualify

for Deminimus Exemption.

If the amount entered on Line 10 is greater than $1,000, you may elect to report on a monthly or annual basis.

Company Officer or Authorized Personnel:

(Print Name)

Company Officer or Authorized Personnel:

(Signature)

Date:

Please submit completed form to NECA via mail or fax:

PRUSF Administrator

NECA

80 South Jefferson Rd.

Whippany, NJ 07981

Phone: (973) 884-8011

Fax: (973) 599-6504

Deminimus Payment Exemption Request Form - Puerto Rico Universal Service Fund Fy 2004-2005