Hearing And/or Speech Impaired Relay Report Form
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1HEARING AND/OR SPEECH IMPAIRED
RELAY REPORT
Mail or deliver hard copy to:
Secretary, Public Service Commission
Heber M. Wells Building
P.O. Box 45585
Salt Lake City, Utah 84145
Report Date:
Company Name:
Reporting Person:
Telephone Number/Extension:
Report Period from: to:
1. Taxable Access Lines
2. Surcharge @ .10 per access line
$
3. Gross Surcharge: (1 X 2)
$
4. Less: Administrative Cost
$
5. Other Adjustments
$
6. Net Surcharge Due and Payable
$
I hereby declare that I read the above report and certify it to be
correct to the best of my knowledge.
Approved by:
Date:
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