Form Psc/cmp 026 - Pay Telephone Service Provider Regulatory Assessment Fee Return printable pdf download

Form Psc/cmp 026 - Pay Telephone Service Provider Regulatory Assessment Fee Return

TO AVOID PENALTY AND INTEREST CHARGES, THE REGULATORY ASSESSMENT FEE RETURN MUST BE FILED ON OR BEFORE «Field1»

Pay Telephone Service Provider Regulatory Assessment Fee Return

Florida Public Service Commission

FOR PSC USE ONLY

STATUS:

Check # __________________________

(See Filing Instructions on Back of Form)

«Field2»

Actual Return

$ _________________

06-03-001

Estimated Return

003001

Amended Return

$ _________________ E

$ _________________ P

06-03-001

PERIOD COVERED:

004011

$ _________________ I

«Field3»

Postmark Date __________________

Initials of Preparer ______________

Please Complete Below If Official Mailing Address Has Changed

(Name of Company)

(Address)

(City/State)

(Zip)

LINE

ACCOUNT CLASSIFICATION

AMOUNT

Gross Operating Revenue (Florida)

Gross Intrastate Revenue

(1)

LESS: Amounts Paid to Other Telecommunications Companies

(

)

(see "2. Fees" on back)

TOTAL REVENUES for Regulatory Assessment Fee Calculation

(Line 2 less Line 3)

Regulatory Assessment Fee Due - (Multiply Line 4 by 0.0020)

Penalty for Late Payment (see "3. Failure to File by Due Date" on back)

Interest for Late Payment (see "3. Failure to File by Due Date" on back)

Extension Payment Fee (see "4. Extension" on back)

(2)

TOTAL AMOUNT DUE (MINIMUM $100.00)

10.

Number of pay telephones in operation at close of period covered by

this Return

(1) These amounts must be intrastate only and must be verifiable (see "2. Fees" on back).

(2) Regardless of the gross operating revenue of a company, a minimum annual regulatory assessment fee of $100 shall be imposed as provided in

Section 364.336, Florida Statutes.

I, the undersigned owner/officer of the above-named company, have read the foregoing and declare that to the best of my knowledge and belief the above

information is a true and correct statement. I am aware that pursuant to Section 837.06, Florida Statutes, whoever knowingly makes a false statement in writing with

the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree.

(Signature of Company Official)

(Title)

(Date)

Telephone Number

(

)

Fax Number (

)

(Preparer of Form - Please Print Name)

F.E.I. No.

PSC/CMP 026 (Rev. 04/07)