TELECOMMUNICATION COMPANY REVENUE AND ASSESSMENT REPORT
WYOMING UNIVERSAL SERVICE FUND
Section I. General Information:
WY ___________________
Check any that apply:
Company Reporting Code:
_____________________________
Initial report ( )
Company name:
_______________________________
Amended report ( )
Attention:
__________________________________
Change of address ( )
Address:
______________________________
Final report ( )
City, State, Zip:
Payment by EFT ( )
Reporting for the month of____________, 2007
Section II. Wyoming retail revenue for the reporting period:
1.
Local exchange service.
1$____________
2.
Local private line.
2.____________
3.
Cellular/PCS/Mobile.
3.____________
4.
Intrastate switched toll.
4.____________
5.
Toll private line.
5.____________
6.
Alternate access and directory.
6.____________
7.
Paging.
7.____________
8.
Pay telephone.
8.____________
9.
Other services and charges.
9.____________
10.
Total Wyoming revenue. Add lines 1 through 9.
10.$____________
0.00
11.
Less revenue from wholesale transactions (see Rule 500(n) of the WPSC Rules)11.(___________)
12.
Total Wyoming retail revenue. Line 10 less line 11.
12.$____________
0.00
Section III. WUSF assessment for the reporting period:
13.
WUSF assessment rate.
13.
x 1.05 %
0.00
14.
Total WUSF assessment. Multiply line 12 by line 13.
14.$____________
Section IV. Reconciliation with prior periods and amount due:
15.
Amount due from prior reporting periods.
15.____________
16.
Credit for overpayment from prior reporting periods.
16.____________
17.
Overpayment. If the total of lines 14 and 15 is less than line 16.
17.$____________
[An overpayment should be shown as a credit on your next report.]
18.
Amount due. If the total of lines 14 and 15 is greater than line 16.
18.$____________
Section V. Payment and due date:
Make checks payable to:
Wyoming Universal Service Fund.
Mail this report and your payment to:
2515 Warren Avenue, Suite 300
Cheyenne, WY 82002
Section VI. Oath:
Under penalty of perjury, I declare that I have examined this report, and that it is true, correct and
complete to the best of my knowledge, information and belief.
Sign
Print your
Here:
_____________________________
_________________________
Signature
Name and title
Date _______________
Phone Number_____________________________
WUSF 1 Rev 03/07