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Gross Receipts Tax Fund Assessment - South Dakota Public Utilities Commission - 2002-2003

SOUTH DAKOTA PUBLIC UTILITIES COMMISSION

GROSS RECEIPTS TAX FUND ASSESSMENT

For the Calendar Year ended December 31, 2002

Payment due on June 1, 2003

TELECOMMUNICATIONS

(Independent, Cooperative, Municipal, AOS, Reseller, Cellular, Radio Common Carrier)

Name of Company & D/B/A__________________________________________________________

Address of Company ______________________________________________________________

______________________________________________________________

Tax ID #_______-_____________________ Phone #____________________

INTRASTATE - SOUTH DAKOTA

Local Service Revenues

Access Service Revenues

Toll Service Revenues

Any Other SD Intrastate Revenues

TOTAL SD INTRASTATE REVENUES

Assessment

(.0015 of South Dakota Gross Revenues

or $250.00 whichever is greater.)

Signed by Company Officer: ______________________________________

______________________________________

(Type or Print Name and Title)

Subscribed and sworn to before me this _____ day of ___________________, 2003.

__________________________________

(Notary Public)

My Commission expires:_____________________

(SEAL)

Checks are to be made payable to the State of South Dakota & are due June 1, 2003. (SDCL 49-1A-5)

Mail form and payment to: Public Utilities Commission, 500 E Capitol, Pierre SD 57501-5070.

Gross Receipts Tax Fund Assessment - South Dakota Public Utilities Commission - 2002-2003