Form Of Annual Return And Revenue Statement (Combo Return) For Calendar Year Ending December 31 Page 4
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4I hereby certify, under penalty of perjury, that the foregoing statement is true to the best of my knowledge
and belief.
Date ______________________
__________________________________________Signature
__________________________________________
Name/Title (typed or printed)
There is a $5 filing fee. Please issue a check made payable to the Comm of MA-DTC.
Do not staple the check to the forms.
Mail the original plus two (2) copies of the completed Annual Return and Revenue
Statement, with the $5 check, plus two (2) photocopies of the check to:
Office of Consumer Affairs & Business Regulation
MA Department of Telecommunication & Cable
Attn: Competition Division
Two South Station
Boston, MA 02110
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