Telephone Surcharge Transmittal Form- California
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1COMBINED CALIFORNIA PUC
TELEPHONE SURCHARGE TRANSMITTAL
MONTH ENDED______/_______ SIX-MONTH ENDED _______/_______
(MM)
(YYYY)
(6 , 12)
(YYYY)
Carrier Name: _____________________________________________________________________________
Utility Identification Number:
or ____ check here, if application/registration pending
.
1. TOTAL INTRASTATE END-USER BILLINGS SUBJECT TO SURCHARGE FOR THE PERIOD:$________________________
2. UNIVERSAL LIFELINE TELEPHONE SERVICE PROGRAM (ULTS)
_____________________ +/(-) _______________________ + ______________________ = ____________________________________
Surcharge Amount Due
Adjustments
Interest/Penalty
Total
Make check* payable to ULTS. Send check and a signed copy of this form to: ULTS, File No. 74311, PO Box 60000, San Francisco,
CA 94160
3. CALIFORNIA RELAY SERVICE AND COMMUNICATIONS DEVICE FUND (CRS/CDF)
_____________________ +/(-) _______________________ + _____________________ = ____________________________________
Surcharge Amount Due
Adjustments
Interest/Penalty
Total
Make check payable to DEAF Trust. Send check and a signed copy of this form to: DEAF Trust, File No. 74409, PO Box 60000, San
Francisco, CA 94160
4. CALIFORNIA HIGH COST FUND A (CHCF-A)
_____________________ +/(-) _______________________ + _____________________ = ____________________________________
Surcharge Amount Due
Adjustments
Interest/Penalty
Total
Make check* payable to CHCF-A. Send check and a signed copy of this form to: CHCF-A, PO Box 45118, San Francisco, CA
94145-0118.
5. CALIFORNIA HIGH COST FUND B (CHCF-B)
_____________________ +/(-) _______________________ + _____________________ = ____________________________________
Surcharge Amount Due
Adjustments
Interest/Penalty
Total
Make check* payable to CHCF-B. Send check and a signed copy of this form to: CHCF-B, File No. 73755, PO Box 60000, San
Francisco, CA 94160.
6. CALIFORNIA TELECONNECT FUND (CTF)
_____________________ +/(-) _______________________ + _____________________ = ____________________________________
Surcharge Amount Due
Adjustments
Interest/Penalty
Total
Make check* payable to CTF. Send check and a signed copy of this form to: CTF, PO Box 45254, San Francisco, CA 94145-0254.
I hereby certify that this return, including accompanying schedules and statements, has been examined by me and to the best of my
knowledge and belief is a true, correct and complete return.
____________________________________________________________________________(______)______ -_________-______
SIGNATURE
DATE
TELEPHONE NUMBER
EXT.
Typed Name___________________________________________________ Title _________________________________________
Name of Reporting Agent if not carrier:___________________________________________________________________________
Street ______________________________________________________________________________________________________
City ________________________________________________________State ___________ Zip Code _______________________
SEND A SIGNED COPY OF THIS FORM TO:
CALIFORNIA PUBLIC UTILITIES COMMISSION
PUBLIC PROGRAMS BRANCH, TELECOMMUNICATIONS DIVISION
505 VAN NESS AVE
SAN FRANCISCO, CA 94102
* Payment by Automated Clearing House (ACH) is available. For approval of payment by ACH, please send an email to telcofiling@cpuc.ca.gov.
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