De Minimis Payment Exemption Request Form - Puerto Rico Universal Service Fund printable pdf download

De Minimis Payment Exemption Request Form - Puerto Rico Universal Service Fund

PUERTO RICO UNIVERSAL SERVICE FUND

FY 2011-2012

De minimis Payment Exemption Request

This form may be submitted to request De minimis Exemption from reporting to the Puerto Rico Universal

Service Fund (PRUSF), in accordance with the Puerto Rico Universal Service Regulations #7795 Section

12.4. Please use this form to notify the PRUSF Administrator that you fall within the De minimis

Exemption range of an annual telecommunications gross revenue less than $25,000.

Company Code: PR- ___________ Company Name: _____________________________________

Street Address: ____________________________________________________________________

City/State/Zip: ____________________________________________________________________

Filing Instructions

Line 1 -Enter total projected revenues for July 2011–June 2012 as reported on the 2011/2012 Carrier

Remittance Worksheet.

1. Projected Fiscal Period Revenues: (July 2011–June 2012)……….

If the amount entered on Line 1 is $25,000 or less, you may qualify for a De minimis Exemption from the

PRUSF for the Fiscal Year (July 2011 – June 2012). At the end of the Fiscal Year, you will be required to

true up your projection to actuals, to ensure you qualify for De minimis Exemption.

If the amount entered on Line 1 is greater than $25,000, please submit your Carrier Remittance

Worksheets on a monthly basis per the instructions.

Company Officer or Authorized Personnel: ______________________________

(Print Name)

Company Officer or Authorized Personnel: ______________________________

(Signature)

Date: __________________________________

Please submit completed form to Solix mail or fax:

PRUSF Administrator

Solix, Inc.

30 Lanidex Plaza West

Parsippany, NJ 07054

Phone: (973) 581-5393

Fax: (973) 599-6504

De Minimis Payment Exemption Request Form - Puerto Rico Universal Service Fund