Universal Access Fund Quarterly Deposit Report Form (Page 2 of 3) in pdf

Universal Access Fund Quarterly Deposit Report Form Page 2

(Revised 9/2/98)

Remit funds shown on line 3 of the preceding page (if the amount is $187.50 or more),

via one of the following methods: Circle the method used: A, B, or C.

Wire funds to:

SouthTrust Bank

ATL

ABA 061000256

Credit: GPSC UAF

Account # 60 834 999

Make checks payable to:

GPSC UAF

SouthTrust Bank

(Include account # 60 834 999 on check)

P.O. Box 740097

Atlanta, GA 30374-0097

For companies who are SouthTrust customers:

Contact the SouthTrust Public Institutions Department at (404) 853-5657 to initiate a

transfer of funds.

IF NO FUNDS ARE REQUIRED:

Complete lines 1, 2, and 3 on the previous page. Sign and mail this statement to:

Director, Utilities Finance Section

ATTN: Gi Gi McGhee

Georgia Public Service Commission

47 Trinity Washington Street, SW

Atlanta, GA 30334-5701

I certify, under penalty of law, that the above information is true and correct to the best of my

knowledge and belief and as of the date indicated, I have remitted the required assessment to

the fund administrator.

_____________________________________ ___________________________________

Authorized Signature

Date

_____________________________________ ___________________________________

Title

Print or type name of Authorized Signature

Universal Access Fund Quarterly Deposit Report Form Page 2