Form 25818 - North Dakota Telecommunications Gross Receipts Tax

Office of State Tax Commissioner

2003 North Dakota Telecommunications Gross Receipts Tax

(North Dakota Century Code ch. 57-34)

Report for the Calendar Year ending December 31, 2002.

Due May 1, 2003

Company Name __________________________________________ Federal Employer ID No.

—

Mailing Address _________________________________________ Social Security No.

—

City, State, Zip Code_______________________________________ Contact Person __________________________________________

Address of COMPANY, not agent, if different from above:

Phone No. ______________________________________________

Mailing Address__________________________________________ Actual Physical Address ___________________________________

City, State, Zip Code ______________________________________ City, State, Zip Code ______________________________________

See instructions on reverse side

2002 Telecommunications Carrier Gross Receipts From Retail Sales

1. Telecommunications service originated AND terminated in North Dakota and billed

to a North Dakota station (include essential and nonessential service) .......................................... $_____________

2. Interstate and international service originated OR terminated in North Dakota and

billed to North Dakota station (include essential and nonessential service) ................................... _____________

3. Cellular and other mobile services provided by the home service provider of a customer

whose place of primary use is in North Dakota ............................................................................... _____________

4. Gross receipts from pay telephones located in North Dakota ......................................................... _____________

5. Telegraph service billed to a North Dakota station ......................................................................... _____________

6. Amounts assessed against members for the operation and maintenance of the

business (applies to mutual companies - see instructions) .............................................................. _____________

7. Recovered telecommunications services charges previously written off as uncollectible .............. _____________

8. Charges to another telecommunications carrier for directory assistance originated by a caller

in this state ...................................................................................................................................... _____________

9. Total Taxable Gross Receipts (sum of lines 1-8) ............................................................................................................ $_____________

Deductions

10. State and local sales and use taxes and federal excise taxes if included on line 9 .......................... _____________

11. Amounts paid to another telecommunications carrier for directory assistance originated by a

caller in this state ............................................................................................................................ _____________

12. Telecommunications service charges written off as uncollectible if included on line 9 ................. _____________

13. North Dakota telecommunications gross receipts taxes paid by the subscriber if included on

line 9 ................................................................................................................................................ _____________

14. Amounts collected to preserve and advance universal service if included on line 9 ...................... _____________

15. Total Deductions (sum of lines 10-14) .............................................................................................

_____________

16. Adjusted Gross Receipts (line 9 less line 15) ................................................................................................................

$_____________

17. Tax rate (2½ percent) .......................................................................................................................................................

_____________

.025

18. TAX ON AMOUNT ON LINE 16 (line 16 multiplied by line 17) .......................................................................................

$_____________

Do not remit with this form

I declare under the penalties of N.D.C.C. § 12.1-11-02, which provides for a Class A misdemeanor for making a false statement in a governmental matter, that this

return, including any accompanying schedules and statements, has been examined by me and to the best of my knowledge and belief is a true, correct, and complete

return.

Date: ____________________

Signature of Officer: _________________________________________

Title: ___________________________________

25818