Form 800 - Annual Fee Statement For Cpuc Utilities Reimbursement Account

Fund 0462-PUCURA

TELCO/A - Webform

CALIFORNIA PUBLIC UTILITIES COMMISSION

800

STATE OF CALIFORNIA

PO Box 942867

Sacramento CA 94267-7081

December 15, 2011

(Circle One)

Utility Type:

CEC CER CLC CLR IEC

Utility ID Number:

U-

IER

LEC PCC RTU

Utility Name:

Utility Address:

Utiltiy City, State Zip:

Name of Report Preparer:

Annual Fee Statement for CPUC Utilities Reimbursement Account, California Cellular Carriers or Telephone

and Telegraph Corporations, pursuant to Chapter 2.5 Part 1, Division 1, Public Utilities Code, for the period

January 1, 2011 to December 31, 2011.

Utilities shall make payment of the fee to the Commission on or before January 15,

2012, consistent with Section 433(a) of the California Public Utilities Code.

1. Gross Intrastate revenue(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$______________

2. Less Intrastate revenue(s) (if reported on line 1):

A. Directory advertising and sales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$______________

B. Terminal equipment sales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

C. Inter-utility sales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$______________

D. Total of above exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$______________

3. Adjusted Intrastate revenue(s) (line 1 minus line 2D) . . . . . . . . . . . . . . . . . . . . . . $______________

. . .

4. Fee (multiply line 3 by .0018 or enter actual amount billed)

. . . . . . . . . . . . . . . . .

$______________

5. Optional uncollectibles: Rate case factor_____________

(multiply factor by line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________

6. Optional adjustments (enter both or neither):

A. Interest earned on fees collected. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$______________

B. Administrative costs on fees collected . . . . . . . . . . . . . . . . . . . . . . . . . .

$______________

C. Subtotal (line 6A minus line 6B, if used) . . . . . . . . . . . . . . . . . . . . . . . . . . .

$______________

7. Fees Due (line 4 minus line 5 if used; plus or minus line 6C) . . . . . . . . . . . . . . . . .

Verification: I hereby declare the foregoing information is true and correct to the best of my knowledge and belief.

Type or print Name and Title

(Area Code)

Phone Number

Date

Signature

Please send remittance payable to "CPUC" with this completed and signed fee statement to the above address.

All checks returned from the bank will incur a $10 service charge to the CPUC.

For more information, contact: Claudette Carolina-Blanson (415) 703-2470

Form 800 - Annual Fee Statement For Cpuc Utilities Reimbursement Account - 2011

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