Form Sfn 19436 - North Dakota Telecommunications Relay Service Fund Quarterly Surcharge Return

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NORTH DAKOTA TELECOMMUNICATIONS RELAY SERVICE FUND
QUARTERLY SURCHARGE RETURN
INFORMATION TECHNOLOGY DEPARTMENT
SFN 19436 (7-2006)
Federal Tax ID
Quarter Ending
Due Date of this Return
Name
Address
City
Zip Code
State
1st Month of Quarter
2nd Month of Quarter
3rd Month of Quarter
Column A
Column B
Column C
1. Number of access lines
2. Number of cellular and/or radio numbers
3. Total (Line 1 plus Line 2)
4. Total collected (Line 3 X .038)
$
$
$
($0.04 less 5% Administrative Expenses = .038)
$
TOTAL DUE WITH RETURN (Total of Line 4, Column A, B and C)
Last Day of Business
If out of business, check this box and enter the last day of business.
Name of New Owner
If change in ownership, check this box and
complete the following information.
Address of New Owner
State
City
Zip Code
If information regarding preparer has changed, check this box.
Name of Preparer
Title
E-mail Address
Telephone Number
I declare that this return has been examined by me and to the best of my knowledge and belief is a true, correct and
complete return.
Signature of Preparer
Date
PLEASE DO NOT WRITE IN THIS SPACE
MAIL TO:
Information Technology Department
600 East Boulevard Ave Dept 112
Bismarck ND 58505-0100

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