Dual-Party Relay Sucharge Remittnace Form - Nebraska
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1STATE OF NEBRASKA
DUAL-PARTY RELAY SUCHARGE REMITTNACE
TELEPHONE COMPANY
____________________________________________
REPORT FOR PERIOD ENDING
______________________________________
Total number of lines
Less: Exceptions
Total number of lines subject to surcharge
Factor (per access line):
X
$0.07
TOTAL
Less: Uncollectible Amounts
Add: Recoveries on Uncollectibles
TOTAL DUE
*
* The Total Due amount may not tie back to the number of lines
subject to surcharge because of partial month billing or exceptions.
Signature
Date
For Commission Use Only
Check No.
Date Deposited
Date Posted
Name, Address and Phone Number of Preparer
The number of local exchange service lines is calculated and billable on a monthly basis. The
proceeds from the surcharge shall be remitted to the Commission monthly no later than thirty (30)
days after the end of the month in which they were collected.
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