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Special Fee Remittance Form - Wyoming Relay Service Fund Of Telecommunications For The Communications Impaired Act Of State Of Wyoming

State of Wyoming

Telecommunications for the Communications Impaired Act

Wyoming Relay Service Fund

Special Fee Remittance

Telephone Company:

_____________________________________________________

Communities Served:

_____________________________________________________

________________________________________________________________________

Report for Month Ending:

_________________________________________________

Total number of access lines subject to special fee:

$ __________

$0.06

TOTAL:

$ __________

Less: Uncollectible Amounts (if any), Adjustments:

__________

Subtotal:

Less: 1% Administrative Fee if authorized

$ __________

(subtract 1% of above subtotal)

$ __________

TOTAL DUE:

___________________________________________

__________________

Name, Address and Phone Number of Preparer

Date

The number of local exchange access lines is calculated and billable on a monthly basis.

The proceeds from the special fee shall be remitted to the Division of Vocational

Rehabilitation monthly no later than thirty days after the end of the month in which

they were collected.

Special Fee Remittance Form - Wyoming Relay Service Fund Of Telecommunications For The Communications Impaired Act Of State Of Wyoming