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Telecommunications Services Surcharge Worksheet For 911-Enhanced Emergency Reporting System - Delaware Divsion Of Revenue Page 3

State of Delaware

TELECOMMUNICATIONS SERVICES SURCHARGE WORKSHEET FOR

Divsion of Revenue

TELEPHONE RELAY SERVICE FUND

P.O. Box 2340

(Must be attached to Form LM11)

Wilmington, DE 19899-2340

Wirelines - Business/Residential and Wireless - Personal and Business

ENTIRE STATE

38. Wireless Line Count for Personal and Business

39. Non-Centrex Line Count (Include BRI Lines.)

40. Number of Centrex Systems with Less than 9 lines and Centrex BRI lines.

41. Add Lines 38 and 39 and 40 for total count

42. Multiply Line 41 by $0.02

43. Number of Lines in Centrex Systems with More than 9 lines

44. Multiply Line 43 by $0.0022

45. Number of Primary Rate Interface ISDN systems

46. Multiply Line 45 by $0.10 (Surcharge rate times 5)

47. Add Lines 42 and 44 and 45 for total Billable Surcharge

48. Minus: Billing Adjustments

49. Corrected Billing

50. Minus: Uncollectables

51. Billing after Uncollectables

52. Minus: Adjustment for Refusal to pay

53. Net Billing

54. Minus: Adminstrative Costs

55. TOTAL TO BE REMITTED TO RELAY SERVICE FUND:

(Line 53 minus Line 54.)

(Enter on Line 5 of Form LM11.)

*DE53613039999*

11/15/2012

Telecommunications Services Surcharge Worksheet For 911-Enhanced Emergency Reporting System - Delaware Divsion Of Revenue Page 3