Universal Service Fund Monthly Reporting Form - Commonwealth Of Kentucky printable pdf download

Universal Service Fund Monthly Reporting Form - Commonwealth Of Kentucky

COMMONWEALTH OF KENTUCKY

UNIVERSAL SERVICE FUND

Date_____________________________

Reporting Month_____________________________

Carrier Information

Company Name

Company Address

Telephone / Fax

Vendor Number

Classification

Please Circle One

ILEC

CLEC

Cellular

PCS

Monthly Access Line Data

Total Access Lines in Service…………………………………………___________________________

Surcharge Per Access Line.……………………………………………__________$0.08____________

Amount of Surcharge Remitted to Kentucky USF…………………….___________________________

Number of Access Lines Receiving Lifeline Support…………………___________________________

Amount of Reimbursement Requested from Kentucky USF………….___________________________

Signature Block

I hereby attest that the information reported herein is true and accurate to the best of my knowledge.

Company Official _______________________Title_______________________Company Official_________________________

(Printed)

(Signed)

Make check payable to: “Kentucky

Send a copy of this report to:

State Treasurer” and send with this

report to:

Kentucky Public Service Commission

ATTN: Jim Stevens

Finance and Administration Cabinet

211 Sower Blvd.

ATTN: KY USF

P.O. Box 615

702 Capital Ave.

Frankfort, KY 40602

Capitol Annex, Room 488A

Frankfort, KY 40601

Revised 03-13-2008

Universal Service Fund Monthly Reporting Form - Commonwealth Of Kentucky