Gross Receipts Tax Fund Assessment Form - South Dakota Public Utilities Commission printable pdf download

Gross Receipts Tax Fund Assessment Form - South Dakota Public Utilities Commission

SOUTH DAKOTA PUBLIC UTILITIES COMMISSION

GROSS RECEIPTS TAX FUND ASSESSMENT

For the Calendar Year ended December 31, 2006

TELECOMMUNICATIONS

(Independent, Cooperative, Municipal, AOS, Reseller, Cellular, Radio Common Carrier)

Name of Company & D/B/A__________________________________________________________

Contact Name & Phone No__________________________________________________________

Address of Company ______________________________________________________________

______________________________________________________________

Tax ID #_______-_________________________

INTRASTATE - SOUTH DAKOTA

Local Service Revenues

Access Service Revenues

Toll Service Revenues

Any Other SD Intrastate Revenues

TOTAL SD INTRASTATE REVENUES

Signed by Company Officer: ______________________________________

______________________________________

(Type or Print Name and Title)

Subscribed and sworn to before me this _________ day of _____________________, 20______.

_____________________________________

(Notary Public)

My Commission expires:_____________________

(SEAL)

Gross Receipts Tax Fund Assessment Form - South Dakota Public Utilities Commission