Form Wusf 1p - Payphone Company Revenue And Assessment Report - Wyoming Universal Service Fund

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PAYPHONE COMPANY REVENUE AND ASSESSMENT REPORT
WYOMING UNIVERSAL SERVICE FUND
Section I. General Information:
WY ________________________________
Check any boxes that apply:
Company Reporting Code:
__________________________________________
Initial report
Company name:
______________________________________________
Amended report
Attention:
_______________________________________________
Change of address
Address:
__________________________________________
Final report
City, State, Zip:
Payment by EFT
Reporting for period of_______________________
Section II. Wyoming retail revenue for the reporting period:
1. Coin-drop revenue.
1.$___________
2. Dial-around compensation.
2.____________
3. Toll commissions.
3.____________
4. Other revenue and charges (p
__________________________________
4.____________
lease describe)
5. Total Wyoming revenue. Add lines 1 through 4
5.$___________
$0.00
Section III. WUSF assessment for the reporting period:
6. ____x 1%___
6. WUSF assessment rate.
7. Total Wyoming Universal Service Fund assessment. Multiply line 5 by line 6.
7.$___________
$0.00
8. Credit for WUSF assessment paid to your local exchange carrier(s).
8(___________)
9. Net Wyoming Universal Service Fund assessment. Subtract line 8 from line 7.
9.$___________
Section IV. Reconciliation with prior periods and amount due:
10. Amount due from prior reporting periods.
10.____________
11. Credit for overpayment from prior reporting periods.
11.____________
12. Overpayment. If the total of lines 9 and 10 is less than line 11.
12.$___________
[An overpayment should be shown as a credit on your next report.]
13. Amount due. If the total of lines 9 and 10 is greater than line 11.
13.$___________
Section V. Payment and due date:
Make checks payable to:
Wyoming Universal Service Fund.
2515 Warren Avenue, Suite 300
Mail this report and your payment to:
Cheyenne, WY 82002
Section VI. Oath:
Under penalty of perjury, I declare that I have examined this report, and that it is true, correct
and complete to the best of my knowledge, information and belief.
Sign
Print your
Here:
_____________________________
________________________
Signature
Name and title
Date______________
WUSF 1P Rev 2/03

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