Combined California Puc Telephone Surcharge Transmittal Form

COMBINED CALIFORNIA PUC

TELEPHONE SURCHARGE TRANSMITTAL FORM

MONTH ENDED______/_______ SIX-MONTH ENDED ______/______

(MM )

(YYYY)

(6 , 12) (YYYY)

Carrier Name: _____________________________________________________________________________

Utility Identification Number:

or ____ check here, if application/registration pending.

1. TOTAL INTRASTATE BILLINGS SUBJECT TO SURCHARGE:

$____________________

2. UNIVERSAL LIFELINE TELEPHONE SERVICE PROGRAM

(ULTS)

_____________________ +/(-) _______________________ + ______________________ = _______________________________

Surcharge Amount Due

Adjustments

Interest/Penalty

Total

Make check payable to the above program. Send check and a signed copy of this form to: Bank of America NA,

Mail Code CA9-703-18-02, a/c# 66-01-100-8446565 ULTS, 333 S. Beaudry Avenue, Los Angeles, CA 90017-1466.

3. CALIFORNIA RELAY SERVICE AND COMMUNICATIONS DEVICE FUND (CRS/CDF)

_____________________ +/(-) _______________________ + _____________________ = _______________________________

Surcharge Amount Due

Adjustments

Interest/Penalty

Total

Make check payable to the above fund. Send check and a signed copy of this form to: Bank of America NA,

Mail Code CA9-703-18-02, a/c#66-01-100-5219780 DEAF, 333 S. Beaudry Avenue, Los Angeles, CA 90017-1466

4. CALIFORNIA HIGH COST FUND-A (CHCF-A)

_____________________ +/(-) _______________________ + _____________________ = _______________________________

Surcharge Amount Due

Adjustments

Interest/Penalty

Total

Make check payable to the above fund. Send check and a signed copy of this form to: California Public Utilities

Commission, Telecommunications Division, Public Programs Branch, 505 Van Ness Avenue, San Francisco, CA 94102

5. CALIFORNIA HIGH COST FUND-B (CHCF-B)

_____________________ +/(-) _______________________ + _____________________ = _______________________________

Surcharge Amount Due

Adjustments

Interest/Penalty

Total

Make check payable to California High Cost Fund-B. Send check and a signed copy of this form to: California High

Cost Fund-B, File No 73755, PO Box 60000, San Francisco, CA 94160-3755

6. CALIFORNIA TELECONNECT FUND (CTF)

_____________________ +/(-) _______________________ + _____________________ = _______________________________

Surcharge Amount Due

Adjustments

Interest/Penalty

Total

Make check payable to California Teleconnect Fund. Send check and a signed copy of this form to: California

Teleconnect Fund, PO Box 45254, San Francisco, CA 94145-9852.

I hereby certify that this return, including accompanying schedules and statements, has been examined by me and to the

best of my knowledge and belief is a true, correct and complete return.

____________________________________________________________________________(______)______ -_________-______

SIGNATURE

DATE

TELEPHONE NUMBER

EXT.

Typed Name___________________________________________________ Title ________________________________________

Name of Reporting Agent if not carrier:_________________________________________________________________________

Street ______________________________________________________________________________________________________

City ________________________________________________________State ___________ Zip Code ______________________

SEND A SIGNED COPY OF THIS FORM TO:

CALIFORNIA PUBLIC UTILITIES COMMISSION

PUBLIC PROGRAMS BRANCH, TELECOMMUNICATIONS DIVISION

505 VAN NESS AVE

SAN FRANCISCO, CA 94102

REVISED 09/99

Combined California Puc Telephone Surcharge Transmittal Form - 1999

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