Colorado Hcsm Declaration Of De Minimis Form
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1Colorado Public Utilities Commission
Declaration of De Minimis Form
For the Colorado High Cost Support Mechanism
For the Period January 1, 2008 through June 30, 2008
FILING DUE SEPTEMBER 1, 2008
Company Name:*
Company IRS Employer Identification No.#: *
*
Company Principal Communications Business:
Cap/CLEC
Cellular/PCS/SMR
IXC
Local Reseller
OSP
Paging & Messaging
Payphone Service
Pre-paid Card
Private Service
Satellite
Shared Tennant
Toll Reseller
Wireless Data
ISP Provider
Other __________
Total Colorado intrastate telecommunications revenues from end-users. (Use
‘Amount’ from worksheet instructions on determining if de minimis or line 232
from worksheet)
Company Contact Person:*
Phone:
E-mail address:*
Company Address:*
________________________________________________________
City
State
Zip
________________
After completing the de minimis worksheet of the instructions, the above-named company has
determined that it is not required to file the Colorado High Cost Support Mechanism worksheet for
the following reason(s):
[ ]
Company had no Colorado intrastate revenue for the first six months of 2008.
[ ]
Contribution to CHCSM was below de minimis level ($5,000) in the first six
months calendar year of 2008.
[ ]
Other (please explain)
I certify that the above-named provider of telecommunications services is not required to
file the Colorado High Cost Support Mechanism Worksheet that is due on September 1,
2008. I understand that willfully false statements are punishable by fine under Article 7,
Title 40 of the Colorado Revised Statutes.
Signed: _______________________________Date: _____/_____/____
Print Name of Signatory: ______________________________________
Please return this form by September 1, 2008 to the following address:
Colorado High Cost Support Mechanism
1560 Broadway, Suite 250
Denver, CO 80202
*
)
(Required field
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