Nebraska Usf & E911 Remittance Worksheet - Nebraska Universal Service Fund
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1Nebraska USF & E911 Remittance Worksheet
Effective April, 2007
COMPANY IDENTIFICATION
COMPANY:
CONTACT NAME:
PHONE #:
CHECK HERE FOR THE NEBRASKA STATE TREASURER TO INITIATE YOUR ELECTRONIC FUND TRANSFER
UNIVERSAL SERVICE FUND
COMPANY NUSF CODES
DESCRIPTION
FCC FORM
REVENUES
NE
NE
1.
FIXED LOCAL EXCHANGE SERVICE
499-A, Ln 404
NE
NE
2.
FIXED LOCAL PRIVATE LINE SERVICE
499-A, Ln 406
NE
NE
3.
OTHER FIXED LOCAL SERVICE REVENUE
499-A, Ln 408
NE
NE
4.
MOBILE MONTHLY ACTIVATION CHARGES
499-A, Ln 409
5.
MOBILE USAGE CHARGES
499-A, Ln 410
SUBMISSION DATE
6.
PREPAID TOLL CALLING SERVICES
499-A, Ln 411
7.
ALT. ACCESS & DIRECTOR TOLL SERVICES
499-A, Ln 413
8.
SWITCHED TOLL SERVICES
499-A, Ln 414
REVENUE DATA PERIOD
9.
TOLL PRIVATE LINE SERVICES
499-A, Ln 415
Monthly
Quarterly
10.
OTHER TOLL SERVICE REVENUE
499-A, Ln 417
11.
AUTHORIZED ADJUSTMENTS TO RETAIL REVENUES:
12.
TOTAL INTRASTATE RETAIL REVENUES (Sum of Lines 1-11):
TYPE OF SUBMISSION
13.
AUTHORIZED ADJUSTMENTS TO NUSF ASSESSMENT:
Original
Revision
14.
NUSF ASSESSMENT ([Line 12 x 6.95%] + Line 13):
WIRELESS ENHANCED 911 FUND
DATA PERIOD
LINES SERVED
LINES COLLECTED
REVENUES
COMPANY INFORMATION (COMPLETE IF NEW COMPANY OR IF INFORMATION HAS CHANGED)
COMPANY:
CONTACT NAME:
PHONE #:
EMAIL ADDRESS:
FAX #:
ADDRESS:
CITY:
STATE:
ZIP:
CERTIFICATION
DATE
AGENT NAME
AGENT TITLE
AGENT SIGNATURE
Mail to:
Nebraska Universal Service Fund
Questions?
Brandy Zierott
NOTE:
ALL PAYMENTS MUST BE
P.O. Box 94927
Phone: (402) 471-0246
MADE ELECTRONICALLY
Lincoln, NE 68509-4927
E-Mail:
brandy.zierott@psc.ne.gov
VIA ACH TO NEBRASKA
or Fax to:
(402) 471-0214
Website:
STATE TREASURER
REMITTANCES ARE DUE ON THE 15TH DAY AFTER THE END OF THE REVENUE DATA PERIOD!
REV. 3-23-2007
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