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Revised Universal Access Fund Quarterly Deposit Report Form - Georgia Public Service Commission

GEORGIA PUBLIC SERVICE COMMISSION (GPSC)

TELECOMMUNICATIONS UNIVERSAL ACCESS FUND (UAF)

REVISED UNIVERSAL ACCESS FUND QUARTERLY DEPOSIT REPORT

FOR THE QUARTER ENDED: ________________________

From (Company):

Current Address:

____________________________________

(Name that appears on your Certificate)

____________________________________

(Name in which you are doing business)

______________________________________

____________________________________

(Any other name used)

Certificate Number(s): _____________________

Prepared By:

(Issued by the GPSC)

Phone Number: ______________________

1. Quarterly Revenue:

2. Contribution Factor:

1.4% (0.014)

3. Quarterly Contribution Requirement = (1) x (2) =

******

The amount of your quarterly deposit to GPSC UAF equals the amount on line 3 above.

However, if the amount on line 1 is less than $12,500, No Contribution Is Required. Simply Mail

The Completed Form To The Commission

1. IF A REMITTANCE IS REQUIRED

(Sign and mail a copy of this report to):

Dorothy Buckner

Telecommunications Unit

Georgia Public Service Commission (GPSC)

244 Washington Street, SW

Atlanta, GA 30334-5701

(Include a copy of the remittance along with the copy of the report to GPSC).

(Revised 12/14/2010)

Revised Universal Access Fund Quarterly Deposit Report Form - Georgia Public Service Commission