Tdd Surcharge For Assistance To Persons With Impaired Speech Or Hearing Report Form - Public Utilities Commission Of Nevada
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1PUBLIC UTILITIES COMMISSION OF NEVADA
TDD Surcharge for Assistance to Persons with Impaired Speech or Hearing Report Form
Company Name:
_____________________________________________________________
CPC or CMRS No:
_____________________________________________________________
Company Address:
_____________________________________________________________
_____________________________________________________________
Telephone:
_____________________________________________________________
_____________________________________________________________________________________
Preparer Name:
_____________________________________________________________
Preparer Company:
_____________________________________________________________
Address:
_____________________________________________________________
Telephone:
_____________________________________________________________
_____________________________________________________________________________________
Reporting Period: ______________________ to ________________________
Surcharge Month
Number of Lines
Rate Per Line
______________
_____________
x
$0.07
=
$_________________
______________
_____________
x
$0.07
=
$_________________
______________
_____________
x
$0.07
=
$_________________
Subtotal
$_________________
Plus Interest Income Pursuant to NAC 707.040
$_________________
(Attach a copy of your bank statement)
Less Administrative Costs
$_________________
(Attach a worksheet detailing costs associated
with the collection of the surcharge for this quarter)
TOTAL REMITTANCE
$_________________
Remittance Address:
Public Utilities Commission of Nevada
ATTN: Fiscal Services
1150 E. William Street
Carson City NV 89701-3109
Reporting Period
Remittance Due Date
July 1, 2012 – September 30, 2012
October 31, 2012
October 1, 2012 – December 31, 2012
January 31, 2013
January 1, 2013 – March 31, 2013
April 30, 2013
April 1, 2013 – June 30, 2013
July 31, 2013
______________________________________________________________________________________________________
Name and title of company official responsible for preparation of this report:
______________________________________
________________________________
Name and Title (print or type)
Signature
______________________________________________________________________________________________________
Name and title/affiliation of non-company person preparing this report (if applicable):
_____________________________________
________________________________
Name and title/affiliation (print or type)
Signature
______________________________________________________________________________________________________
Subscribed to and sworn before me this _______ day of _________________, 201__:
__________________________________________
Notary Public
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