SOUTH DAKOTA PUBLIC UTILITIES COMMISSION
GROSS RECEIPTS TAX FUND ASSESSMENT
For the Calendar Year ending December 31, 2014
(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 #_______-_________________________
* 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
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
Late payment fees
Signed by Company Officer: ______________________________________
(Type or Print Name and Title)
Subscribed and sworn to before me this _________ day of _____________________, 20______.
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: ______________________