Form 751 - Surcharge Remittance Form
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1OREGON PUBLIC UTILITY COMMISSION RESIDENTIAL SERVICES PROTECTION FUND
SURCHARGE REMITTANCE FORM
Telecommunications Provider’s Name and Business Office Address
Report Month/Year
Month/Year:
______________
Telecommunications Provider:
Quarterly
Monthly
Telephone:
The remittance report and surcharge fees are
City/State:
Zip:
st
due on the 21
calendar day after the close of
each monthly or quarterly billing
Preparer Name:
Telephone:
NOTE: Per OAR 860-033-006
Providers w/ 1000 or more
Company Name (if different from provider):
customers must collect & submit
Preparer e-mail:
RSPF surcharge fees monthly.
Preparer Address:
Providers w/1000 or less
City/State:
Zip:
customers must submit quarterly.
ILEC
CLEC
Radio Common Carrier (wireless)
COMPANY ID#: ______________
1. Number of telephone exchanges in use in Oregon.
1.
2. Total Number of access lines and instruments (wireless) billed and unbilled during report
period.
2.
3. Subtractions
Unpaid access line and wireless instrument billings
a.
3a.
Number of lines paid by others due to interconnection agreements with:
b.
3b.
Exempt lines
c.
.
No dial out or dial in capability
i.
3c.i
ii. Pagers (without dial out or dial in capability)
3c.ii
iii. Coin operated instruments
3c.iii
iv. Security system lines
3c.iv
v. Entities that are exempt from paying the surcharge by federal or state law, including,
but not limited to: regional housing authorities, municipal government bodies or public
corporations, the State, Counties or political subdivisions, Native Americans, who are
enrolled members of a tribe, and located on federally-recognized reservations, foreign
government offices and services receiving exchange access service and certain
federally chartered corporations specifically exempted from state excise taxes by
federal statute, including federal banks and banking associations created under the
Farm Credit System.
3c.v
vi. Other: ___________________________________________________________
3c.vi
Unbilled Access Lines (provide a brief description)
d.
3d.
i.
_________________________________________________________________
ii. _________________________________________________________________
iii. _________________________________________________________________
Total Adjustments (lines 3a through 3d)
e.
3e.
4.
4. Number of lines/instruments subject to surcharge (lines 2 – 3e)
5. Current surcharge per line/instrument
$.05
5.
$ 0.00
6.
6. Surcharge amount due (line 4 x line 5)
7. If this is a final report, please check this box.
Signature Required- Print & Sign
Date
I certify this report is true and correct and complies with Oregon Laws 1987, chapter 290, Section 7
Mail report and payment to:
Public Utility Commission
Residential Service Protection Fund
Make checks payable to: Public Utility Commission
PO Box 2153
Salem OR 97308-2153
Please refer to the accompanying FORM 751 Guidelines to assist you in filling out this form.
You may also contact Julie Thompson, RSPF Specialist at
Julie.Thompson@state.or.us
or 503-373-7915.
FORM751 (07/2007)
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