Quarterly Surcharge Return Form - North Dakota Telecommunications Relay Service Fund

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NORTH DAKOTA TELECOMMUNICATIONS RELAY SERVICE FUND
QUARTERLY SURCHARGE RETURN
INFORMATION TECHNOLOGY DEPARTMENT
SFN 19436 (8-2002)
Name
Federal Tax ID
Quarter Ending
Due Date of this Return
Address
City
State
Zip Code
1st Month of Quarter
2nd Month of Quarter
3rd Month of Quarter
Column A
Column B
Column C
1. Number of access lines
2. Number of cellular and/or radio numbers
3. Total (Line 1 plus Line 2)
0
0
0
4. Total collected (Line 3 X .057)
$
$
$
0.00
0.00
0.00
($0.06 less 5% Administrative Expenses = .057)
TOTAL DUE WITH RETURN (Total of Line 4, Column A, B and C)
$
0.00
Last Day of Business
If out of business, check this box and enter the last day of business.
If change in ownership, check this box and
Name of New Owner
complete the following information.
Address of New Owner
City
State
Zip Code
If information regarding preparer has changed, check this box.
Name of Preparer
Title
E-mail Address
Telephone Number
I declare that this return has been examined by me and to the best of my knowledge and belief is a true, correct and
complete return.
Signature of Preparer
Date
MAIL TO:
PLEASE DO NOT WRITE IN THIS SPACE
Information Technology Department
600 East Boulevard Ave Dept 112
Bismarck ND 58505-0100

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