Form 053106 - Telecommunications Relay Service / Access Program Fund Monthly Report
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1053106
COMMONWEALTH OF KENTUCKY
TELECOMMUNICATIONS RELAY SERVICE FUND
TELECOMMUNICATIONS ACCESS PROGRAM FUND
Date_____________________________
Reporting Month___________________
Carrier Information
Company Name
Company Address
Telephone / Fax
Vendor Number
Classification
Please Circle One
ILEC
CLEC
Monthly Access Line Data
1.
Total Access Lines in Service…………………………………………___________________________
2.
TRS Surcharge Per Access Line.………………………………………__________$0.07____________
3.
Amount of TRS Surcharge Remitted to Fund …..…………………….___________________________
4.
TAP Surcharge Per Access Line…………………….…………………__________$0.02____________
5.
Amount of TAP Surcharge Remitted to Fund………………………….___________________________
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)
Send a copy of this report to:
Make check payable to: “Kentucky State
Treasurer” and send with this report to:
Kentucky Public Service Commission
ATTN: Jim Stevens
JPMorgan Chase GP# 204519 / 204690
211 Sower Blvd.
ATTN: Joseph A. Morales AVP.
P.O. Box 615
Escrow Admin. 15th Floor
Frankfort, KY 40602
4 New York Plaza
New York, NY 10004
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Parent category: Financial