2000/2001 Remittance Worksheet Instructions - Kansas Universal Service Fund Page 16
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17Kansas Universal Service Fund
2000/2001 Remittance Worksheet Instructions
KUSF Support Payment Request Form
To receive KUSF Support, the company must be granted Eligible Telecommunications Carrier
status by the Kansas Corporation Commission.
Section One : Please indicate the method of payment you prefer to receive your KUSF Support
Payments.
Section Two: If you choose payment by check, please enter Company Code and Name of
Company. If you choose payment by Electronic Funds Transfer, please complete entire section.
=====================================================================
Section One:
Please Mark One
Electronic Funds Transfer
Check
Section Two:
Company Code: KS-
Company Name:
Bank Name:
Routing/Transit Number:
Bank Account Number:
Indicate Checking or Savings:
Please submit this form to: Manager, KUSF Administration, 80 South Jefferson Rd., Whippany,
NJ 07981. Phone: 973-884-8011.
Page 16 of 16
Revised 2/00
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