Gross Receipts Tax Fund Assessment Form - 2014

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SOUTH DAKOTA PUBLIC UTILITIES COMMISSION

GROSS RECEIPTS TAX FUND ASSESSMENT

For the Calendar Year ending December 31, 2014

TELECOMMUNICATIONS

(Independent, Cooperative, Municipal, AOS, Reseller, Cellular, Radio Common Carrier)

Name of Company & DBA__________________________________________________________

Contact Name & Phone No__________________________________________________________

Address of Company_______________________________________________________________

Contact Person's Email Address ____________________________________________________

Web Address of Company __________________________________________________________

Tax ID #_______-_________________________

2014 Revenues

* Total South Dakota Intrastate Revenue

Revenues include Wholesale and Retail Sales.

Select Revenues below that are included in your Intrastate Revenue number:

PLEASE CHECK ALL THAT APPLY. UNCHECKED FORMS WILL BE RETURNED FOR COMPLETION.

Monthly Recurring charges and usage charges associated with intrastate voice services

Usage charges associated with directory assistance services

Activation fees

End user roaming charges

Intrastate toll charges

Monthly recurring charges and usage associated with wireless broadband services

Monthly recurring charges and usage charges associated with text messaging services

Monthly recurring charges associated with voice mail services

Monthly recurring charges and usage associated with applications such as games, music, navigation, etc.

Revenue associated with handsets, handset accessories, tablets, tablet accessories and any other equipment sold

Roadside assistance

Late payment fees

Other _________________________________________________________________________________

Signed by Company Officer: ______________________________________

______________________________________

(Type or Print Name and Title)

Subscribed and sworn to before me this _________ day of _____________________, 20______.

_____________________________________

(SEAL)

(Notary Public)

My Commission Expires: _____________________

SDCL 49-1-9.1. Providing false or misleading information to commission as misdemeanor. No person may knowingly provide false or

misleading information to the commission in response to, or in compliance with, any statute, order, tariff, rule, direction, demand, or requirement of

the commission. A violation of this section is a Class 1 misdemeanor. Each separate act of providing false or misleading information pursuant to this

section constitutes a separate offense. This penalty is in addition to any other authorized penalties.

For Official Use Only Date Received: _________________ Amount: __________________________Check No: ______________________