Report Of Gross Operating Revenues Derived From Intra-Kentucky Business - Local Exchange Carriers And Competitive Local Exchange Carriers - Kentucky Public Service Commission
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2Rev. 7/20/2004
KENTUCKY PUBLIC SERVICE COMMISSION
REPORT OF GROSS OPERATING REVENUES DERIVED FROM INTRA-KENTUCKY
BUSINESS FOR THE YEAR ENDING DECEMBER 31, 20______
LOCAL EXCHANGE CARRIERS and COMPETITIVE LOCAL EXCHANGE CARRIERS
Name of Utility Reporting___________________________________________________________
FEIN # (Federal Employer Identification Number)
-
Address of Utility_________________________________________________________________
City___________________________ State _______________ Zip Code_____________________
Telephone Number of Utility________________________________________________________
Fax Number of Utility (if applicable)__________________________________________________
Officer/Contact Person_____________________________________________________________
(Name)
(Title)
* * * * * * * * * * * * * * * * * * * * * * * * * * * *
ASSESSABLE REVENUES OF TELEPHONE UTILITY……………..$_____________________
(to agree with assessable revenues figure on the back of this page)
* * * * * * * * * * * * * * * * * * * * * * * * * * * *
OATH
State of…………………………….)
) ss.
County of………………………….)
_________________________________________________being duly sworn, states that he/she
(Officer)
is ______________________________of the ________________________________________
(Official Title)
(Utility Reporting)
that the above report of gross revenues is in exact accordance with
______________________________________, and that such books accurately show the gross
(Utility Reporting)
revenues of: _________________________________________, derived from Intra-Kentucky
(Utility Reporting)
business for the calendar year ending December 31, 20_________.
________________________________________
(Officer)
(Title)
This the _________________ day of _________________________________, 20__________
____________________________________________________________________________
(Notary Public)
(County)
(Commission Expires)
NOTE: ANY DIFFERENCE BETWEEN THE AMOUNT OF THE GROSS
REVENUES SHOWN IN THE ANNUAL REPORT AND THE AMOUNT
APPEARING ON THIS STATEMENT MUST BE RECONCILED ON THE
REVERSE OF THIS REPORT
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