Tdd Surcharge For Assistance To Persons With Impaired Speech Or Hearing Report Form - Public Utilities Commission Of Nevada Page 3
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3PUBLIC UTILITIES COMMISSION OF NEVADA
TDD Surcharge for Assistance to Persons with Impaired Speech or Hearing Report Form
Company Name:
_____________________________________________________________
CPC or CMRS No:
_____________________________________________________________
Company Address:
_____________________________________________________________
_____________________________________________________________
Telephone:
_____________________________________________________________
E-Mail Address:
_____________________________________________________________
________________________________________________________________________________________________
Preparer Name:
_____________________________________________________________
Preparer Company:
_____________________________________________________________
Address:
_____________________________________________________________
Telephone:
_____________________________________________________________
E-Mail Address:
_____________________________________________________________
_______________________________________________________________________________________________
Reporting Period:
________________________ to _______________________
Surcharge Month
Number of Lines
Rate Per Line
______________
_______________
x
$0.03
=
$_________________
______________
_______________
x
$0.03
=
$_________________
______________
_______________
x
$0.03
=
$_________________
TOTAL REMITTANCE
$_________________
Report form and applicable surcharge are due no later than October 31, January 31, April 30 and July 31 of each year.
Quarterly Reporting Period
Remittance Due Date
Jul 1, 2015 – Sep 30, 2015
Oct 31, 2015
Oct 1, 2015 – Dec 31, 2015
Jan 31, 2016
Jan 1, 2016 – Mar 31, 2016
Apr 30, 2016
Apr 1, 2016 – Jun 30, 2016
Jul 31, 2016
_________________________________________________________________________________________________
I, ___________________________________, on behalf of ______________________________________declare under
[name of signatory]
[regulated entity]
penalty of perjury under the laws of the State of Nevada that I have carefully examined the foregoing information provided to
the Public Utilities Commission of Nevada, and declare it to be a complete and correct statement to the best of my knowledge,
information and belief; and that I have the authority to make these representations and to bind the regulated entity on whose
behalf I am providing this information. I further declare that the foregoing information has been prepared by me or under my
direction.
Signature: ________________________________________
Date:
______________________
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