Telecommunication Company Revenue And Assessment Report Form printable pdf download

Telecommunication Company Revenue And Assessment Report Form

TELECOMMUNICATION COMPANY REVENUE AND ASSESSMENT REPORT

WYOMING UNIVERSAL SERVICE FUND

Company Reporting Code: WY_______

Check any boxes that apply:

Company name: __________________________________

Initial report

Attention: _______________________________________

Amended report

Address: ________________________________________

Change of address

City, State, Zip: ___________________________________

Final report

Payment by EFT

Reporting for the month(s) of: _______________________, 200__

1. Local exchange service.

$ ___________

2. Local private line.

____________

3. Cellular/PCS/Mobile.

____________

4. Intrastate switched toll.

____________

5. Toll private line.

____________

6. Alternate access and directory.

____________

7. Paging.

____________

8. Pay telephone.

____________

9. Other services and charges.

____________

10. Total Wyoming revenue. Add lines 1 through 9.

$ ___________

11. Less revenue from wholesale transactions.

$(__________)

12. Total Wyoming retail revenue. Line 10 less line 11.

$___________

Wyoming Universal Service Fund assessment for the reporting period:

13. WUSF assessment rate (see Table of rates below).

x__________

14. Total Wyoming Universal Service Fund assessment. Multiply line 12 by

$___________

line 13.

Reconciliation with prior periods and amount due:

15. Amount due from prior reporting periods.

$___________

16. Credit for overpayment from prior reporting periods.

$___________

17. Overpayment. The total of lines 14 and 15 is less than line 16.

$___________

[An overpayment should be shown as a credit on your next report.]

18. Amount due. The total of lines 14 and 15 is greater than line 16.

$___________

Make checks payable to: Wyoming Universal Service Fund.

Mail this report and your payment to:

Wyoming Universal Service Fund

P. O. Box 1407

Cheyenne, WY 82003-1407

Reporting period

Rate

Factor

Table of WUSF assessment rates:

July 1, 2000 through June 30, 2001

2.00%

0.0200

4.00%

0.0400

July 1, 2001

Oath: Under penalty of perjury, I declare that I have examined this report, and that it is true, correct and

complete to the best of my knowledge, information and belief.

Sign Here:

Print your Name and title:

Date:

Signature _____________________

_____________________________

________________

Telecommunication Company Revenue And Assessment Report Form

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