Colorado Low-Income Telephone Assistance Program Form - Colorado Public Utilities Commission

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Colorado Low-Income Telephone Assistance Program
2007 1st Quarter Payment Calculation Form
Foregone Revenue of LITAP Program due on April 30, 2007
Company Name:____________________________________________________
Address:
____________________________________________________
____________________________________________________
Contact Person:
Contact Telephone No.:
FORGONE REVENUE & ADMINISTRATION EXPENSES
# of Subscribers
Local
Amount of
Admin
Total
Receiving
Rate
Forgone
Expense
Forgone
MONTH
Assistance
Discount
Revenue
Revenue
Jan
0
$6.50
$0.00
$0.00
$0.00
Feb
0
$6.50
$0.00
$0.00
$0.00
Mar
0
$6.50
$0.00
$0.00
$0.00
$0.00
Payment Calculation
Signature Block
Date Prepared:
Printed name of person
completing this form
Forgone Revenue & Admin Exp
$0.00
Signature
Contact E-mail:
(Signature must be an officer or agent of the company)
Mail completed form with payment to:
Colorado Public Utilities Commission
Low-Income Telephone Assistance Fund #251
1560 Broadway, Suite 250
Denver, CO 80202
CONFIDENTIAL

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