Assistance Program Form - Idaho Telecommunications Service - 2013
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1IDAHO TELECOMMUNICATIONS SERVICE
REVISED 05/13
ASSISTANCE PROGRAM FORM
DUE DATE: 20TH OF EACH MONTH
COMPANY NAME_________________________________________________________________________
REPORTING PERIOD:_________________________________________ TO
____________________________________
SURCHARGE REVENUES:
RESIDENTIAL
BUSINESS
& WIRELESS
SURCHARGE
END USERS
X SURCHARGE =
REVENUES
RESIDENTIAL ACCESS LINES
BUSINESS ACCESS LINES
WIRELESS ACCESS LINES
TOTAL ACCESS LINES
$0.03
PRORATED CHARGES
TOTAL SURCHARGE REVENUES
ASSISTANCE REVENUES:
ITSAP
TOTAL ASSISTANCE
RECIPIENTS X
CREDIT
=
REVENUES
1
TOTAL CREDIT PAID TO RECIPIENTS
$2.50
TOTAL DUE:
COSTS OF PROGRAM ADMINISTRATION
NET SURCHARGE REVENUES
(SURCHARGE LESS CREDITS AND ADMINISTRATIVE COSTS)
PREPARED BY_________________________________________ PHONE_______________________
Questions? Call Alyson Anderson, Admin.
PLEASE MAKE CHECKS PAYABLE TO
IDAHO TELECOMMUNICATIONS ASSISTANCE
PHONE: 801-294-5343; FAX: 801-294-5143
PROGRAM
e-mail:
1964 North 300 East
Centerville, UT 84014
1
Effective July 1, 2013.
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