Looking for a Georgia Legal Forms And Templates? Download it for free!

Revised Universal Access Fund Quarterly Deposit Report Form - Georgia Public Service Commission Page 2

Remit funds shown on line 3 of the preceding page (if the amount is $38.75 or more),

via one of the following methods: Circle the method used: A, B, or C.

Wire funds to:

Wachovia Bank

A Division of Wells Fargo Bank, NA

Atlanta, GA

ABA 061000227

Credit: GPSC UAF

Make checks payable to:

GPSC UAF

P.O. Box 934025

Atlanta, GA 31193-4025

(And attach a copy of remittance form)

For companies who are Wachovia/Wells Fargo customers:

Contact Wachovia Government and Institutional Banking at (678) 589-4328 to

initiate a transfer of funds.

IF NO FUNDS ARE REQUIRED:

Complete lines 1, 2, and 3 on the previous page. Sign and mail this statement to:

Dorothy Buckner

Telecommunications Unit

Georgia Public Service Commission

244 Washington Street, SW

Atlanta, GA 30334-5701

I certify, under penalty of law, that the above information is true and correct to the best of

my knowledge and belief and as of the date indicated, I have remitted the required

assessment to the fund administrator.

_____________________________________

___________________________________

Authorized Signature

Date

_____________________________________

___________________________________

Title

Print or type name of Authorized Signature

(Revised 12/14/2010)

Revised Universal Access Fund Quarterly Deposit Report Form - Georgia Public Service Commission Page 2