Gross Receipts Tax Fund Assessment Form - South Dakota Public Utilities Commission - 2009

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SOUTH DAKOTA PUBLIC UTILITIES COMMISSION
GROSS RECEIPTS TAX FUND ASSESSMENT
For the Calendar Year ended December 31, 2009
TELECOMMUNICATIONS
(Independent, Cooperative, Municipal, AOS, Reseller, Cellular, Radio Common Carrier)
Name of company and dba
Address of company
Contact name and phone number
Contact person's e-mail address
Web address of company
Tax ID #
-
2009 Revenues
*Total South Dakota intrastate revenue
$
*Total interstate revenue
$
*Revenues include wholesale and retail sales.
Method for calculating revenues
Signed by company officer: ________________________________________
(Type or print name and title)
Subscribed and sworn to before me this ________ day of ____________________ , 20_____ .
___________________________________
My Commission expires:_______________________
(Notary Public)
(SEAL)
49-1-9.1. Providing false or misleading information to commission as misdemeanor. No person may knowingly provide false or misleading information to the
commission in response to, or in compliance with, any statute, order, tariff, rule, direction, demand, or requirement of the commission. A violation of this section is a Class 1
misdemeanor. Each separate act of providing false or misleading information pursuant to this section constitutes a separate offense. This penalty is in addition to any other
authorized penalties.
For Official Use Only:
Date Received: _________________ Amount: __________________________Check No: ______________________

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