TELECOMMUNICATION COMPANY REVENUE AND ASSESSMENT REPORT
WYOMING UNIVERSAL SERVICE FUND
Reporting Service: ______________________
Select One
Section I. General Information
Company WY Reporting Code: ________________
Reporting Period: ______________________
Select One
Company Name: _____________________________________
Attention: __________________________________________
Address: ___________________________________________
City, State Zip: ______________________________________
Section II. Wyoming Retail Revenue for the Reporting Period:
1. Local Exchange Service
1. _____________________
$0.00
2. Local Private Line
2. ______________________
$0.00
3. Cellular/PCS/Mobile
3. ______________________
$0.00
4. Intrastate Switched Toll (Long Distance)
4. ______________________
$0.00
5. Alternate Access and Directory
5. ______________________
$0.00
6. Paging
6. ______________________
$0.00
7. Pay Telephone
7. ______________________
$0.00
8. Other Services and Charges
8. ______________________
$0.00
9. Total Wyoming Revenue (Add lines 1 through 8)
9. ______________________
$0.00
10. Less Revenue from Wholesale Transactions
10. _____________________
$0.00
11. Total Wyoming Retail Revenue (Line 9 less line 10)
11. _____________________
$0.00
Section III. WUSF Assessment for the Reporting Period:
12. WUSF Assessment Rate (0.8%)
12. _____________________
0.008
13. Total WUSF Assessment (Multiply line 11 by line 12)
13. _____________________
$0.00
Section IV. Reconciliation with Prior Reporting Periods and Amount Due:
14. Amount Due from Prior Reporting Periods
14. _____________________
$0.00
15. Credit for Overpayment from Prior Reporting Periods
15. _____________________
$0.00
$0.00
16. Amount Due
16. _____________________
Section V. Payment:
Make Checks Payable to:
Wyoming Universal Service Fund
Mail this Report and Payment to:
2515 Warren Avenue, Suite 300 Cheyenne, WY 82002
Section VI. Oath:
Under penalty of perjury, I declare that I have examined this report, and that it is true, correct and complete
to the best of my knowledge, information and belief.
Signature: __________________________________________
Date: _____________________
Print Name and Title: ________________________________
Phone Number: _____________________
WUSF 6/13
CHECK:___________________
INVOICE:___________________
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