Puc Form 751 (31000) - Surcharge Permittance Form - Oregon Public Utility Commission
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1OREGON PUBLIC UTILITY COMMISSION
RESIDENTIAL SERVICES PROTECTION FUND
SURCHARGE REMITTANCE FORM
Telecommunications Provider Name and Business Office Address
Report Month/Year
Provider:
Quarterly
Monthly
Address:
Report due by last day of month/quarter
City/State:
following report period
Zip:
NOTE: OAR 860-033-006 states that
providers with 1,000 or more customers
Provider Email Address:
must collect and submit RSPF surcharge
Company Reporting as a(n)
fees monthly. Providers with less than
1,000 customers shall submit surcharge
ILEC
fees monthly or quarterly.
CLEC
#:
PROVIDER ID
Radio Common Carrier (wireless)
1
1. Number of telephone exchanges in use in Oregon
2. Number of access lines/instruments billed during report period
2
3. Adjustments
3a.
a. Unpaid access line/instrument billings
3b.
b. Number of lines paid by others due to
interconnection agreements with
___________________________________
c. Exempt lines
3c.i.
i. No dial out or dial in capability
3c.ii.
ii. Pagers (without dial out or dial in capability)
3c.iii.
iii. Coin operated instruments
3c.iv.
iv. Security system lines
Other (explain below)
3c.v.
v. Entities who are exempt from paying the surcharge by federal
or state law, including, but not limited to: regional housing
authorities, municipal government bodies or public
corporations, the State, Counties or political subdivisions,
Native Americans, who are enrolled members of a tribe, and
located on federally-recognized reservations, foreign
government offices and services receiving exchange access
service and certain federally chartered corporations specifically
exempted from state exise taxes by federal statute, including
federal banks and banking associations created under the
Farm Credit System.
3c.vi.
vi.
d. Total Adjustments (lines 3a through 3c)
3d
0
4. Number of lines/instruments subject to surcharge (lines 2 + 3d)
4
0
5. Current surcharge per line/instrument
5
$0.10
6. Surcharge amount due (line 4 x line 5)
$0.00
7. If this is a final report, please check this box.
Date
Telephone
I certify this report is true and correct and complies with ORS 759.690(7)
Signature
Required
For assistance or information, please call Damara Paris at 1-800-735-1232, extension 503-373-1413,
E-mail address: damara.paris@state.or.us
Make checks payable to: Public Utility Commission
Mail report and payment to:
Public Utility Commission
Residential Service Protection Fund
PO Box 2153
Salem OR 97308-2153
PUC Form 751 (31000) (Revised 3/18/2005)
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