Form Kusf - Carrier Remittance Worksheet For Incumbent Lecs Only-Kansas Universal Service Fund - 2009/2010
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1Kansas Universal Service Fund
Mar 09 - Feb 10 Carrier Remittance Worksheet For
Incumbent LECS ONLY
A. Company Code KS
E. Revenue Data Month(s):
B. Submission Date
Mar-09
Jun-09
Sep-09
Dec-09
C. KUSF Assessments Collected from Customers
Apr-09
Jul-09
Oct-09
Jan-10
(Collected for Revenue Data Months Reported in Block
E)
May-09
Aug-09
Nov-09
Feb-10
$________________________
D. N/A For ILECs
F.
ORIGINAL
REVISION
Please read complete instructions before completing.
SECTION 1 - CARRIER IDENTIFICATION
1.
Company Name:
1a.
Complete Mailing Address:
1b.
Company Contact Name:
1c.
Telephone:
E-Mail Address (required):
2. Primary Communications Business (Circle primary business and "X " other categories being reported):
ILEC
Agent - Attachment B must be filed for current fiscal year
3.
Agent Name:
3a.
Complete Mailing Address:
3b.
Agent Contact Name:
3c.
Telephone:
E-Mail Address (required):
SECTION 2 - INTRASTATE RETAIL REVENUE DATA
4. LOCAL EXCHANGE SERVICE………………………………………………………………………………………………………………………….
4 .
5. LOCAL PRIVATE LINE
(REPORT TOLL PRIVATE LINE SEPARATELY ON NON-ILEC
WORKSHEET)
5 .
6. WIRELESS, PAGING CHARGES (
Include AirTime and
Roaming) ..……………………………...……………………………
6 .
7. INTERCONNECTED VoIP………………………………………………………………………………………………………………………………………………….
7 .
8. INTRASTATE SWITCHED TOLL
(REPORT SEPARATELY ON NON-ILEC
WORKSHEET)
8 .
9. ALTERNATIVE ACCESS, PAYPHONE, & DIRECTORY…………………………………………………………………………
9 .
10. MISCELLANEOUS & NON-RECURRING…………………………………………………………………………………………………………….
10 .
$0.00
11. TOTAL INTRASTATE RETAIL REVENUE (SUM OF LINES 4 THROUGH 10)
……………
(see instructions)
11 .
12. UNCOLLECTIBLES (BAD DEBT) written off during the reported revenue data month………………………………… 12 .
$0.00
13. NET INTRASTATE REVENUE (SUBTRACT LINE 12 FROM 11)……………………………………………………… 13 .
SECTION 3 - PAYMENT CALCULATION
14. 09/10 ACCESS LINE RATE ………………………..…………………...…..……………………………………………………………………………
14 .
15. ILEC: TOTAL NUMBER OF ACCESS LINES……………………………………………………………………………………………….
15 .
-
16. GROSS KUSF ASSESSMENT …
………………….........……..…………
(LINE 14 x LINE 15, SEE INSTRUCTIONS)
16 .
17. KUSF SUPPORT PAYABLE……(ILECS ONLY ) ……………………………………………………...………………… 17 .
18. Lifeline Discount
# Lifeline
Discount
Total Lifeline
Incumbent LEC
Lines
Per Line
Discount
$
-
$
-
-
Total
$
-
18 .
$
$
-
19. TOTAL KUSF ASSESSMENT (LINE 16 - LINE17 - LINE 18.)
19 .
(Negative amount Equals KUSF payment to ILEC)…………
20. ASSESSMENT TRANSFERRED FROM AFFILIATE/SUBSIDIARY (DUE FROM KS00____________)
…………………….……
20 .
$
-
21. NET KUSF ASSESSMENT/(PAYMENT) DUE (LINE 19 + LINE 20)…………………………………………………………………………...
21 .
Remittance Worksheets are due to GVNW on the 15th day of the current month, unless on a weekend, then due the next business day.
Remittance worksheets received after the 15th of the month are subject to a 1.0% (12% APR) or $100, whichever is greater, Late Worksheet Charge.
Payments received by CoreFirst after the due date are subject to a 1% (APR 12%) Late Payment Charge.
SECTION 4 - CHANGE IN COMPANY STATUS
22. Change in Business Operations:
Business Sold:____________
Business Merged:_______________
Business Ceased:__________________
(Date)
(Date)
(Date)
23. Surviving Legal Entity: ______________________________________
24. Company Sold to/Merged With:_______________________________
SECTION 5 - CERTIFICATION
Under penalties as provided by law, I certify that I have examined this report and to the best of my knowledge and belief it is true, correct and complete. I acknowledge
GVNW's authority to request additional information as necessary and to discuss the Company's KUSF obligations with the designated Agent.
25 .
Date
Officer Name
Officer Signature
Title
26 .
Date
Agent Name
Agent Signature
Title
Send payment to : KUSF, PO Box 1512 Topeka, KS 66611-1512
Questions: 217.862.1550
Fax: 217.698.2715
E-Mail:
KUSF 2009/2010
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