Utah Universal Service Fund Surcharge Remittal Statement Form
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1UTAH UNIVERSAL SERVICE FUND SURCHARGE
REMITTAL STATEMENT
Mail or deliver hard copy to:
Secretary, Public Service Commission
Heber M. Wells Building
P.O. Box 45585
Salt Lake City, Utah 84145
1.
Statement Remittal Date:
2.
Company or Carrier Name:
3.
Reporting Person:
Telephone Number:
4.
Report Period from:
to:
5. Calculations -- Includes Local, Toll, and all other Intrastate Revenues
a.
Retail Intrastate Rates (Revenues)
$
b. Surcharges Billed for Period @
$
(.005 X 5.a.) as of 12/01/2006
c.
Adjusted Rates (note)
$
d.
Surcharges Adjusted (note)
$
e.
Net surcharges (5.b. less 5.d)
$
$
6.
Total Surcharges Remitted this Period
Attach check for this amount
Note: Adjustments for uncollectibles, service adjustments, rebills, etc.
Rates subject to adjustment by future Commission orders.
Original: Secretary, PSC; Copies: Director, Division of Public Utilities; Reporting Company's Records
Form Iss: 2/90
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