Form Rct-111 - Gross Receipts Tax (Grt) Report Telecommunications Page 2

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1110014205

Revenue ID

RCT-111

(12-14)

PAGE 2 OF 7

SOURCE OF GROSS RECEIPTS

Column A

Column B

Column C

PA TAXABLE

USE WHOLE DOLLARS ONLY

INTRASTATE

INTERSTATE

MOBILE

Local Network Service

FCC-5000 – Basic Local Service (Class B Account)

FCC 5001 – Basic Area (Class A Account)

FCC 5002 – Optional Extended Area

(Class A Account)

FCC 5003 – Cellular Mobile (Class A Account)

FCC 5040 – Private Line (Class A Account)

FCC 5060 – Other Basic Area (Class A Account)

Network Access Service

FCC 5081 – End User

FCC 5082 – Switched Access

FCC 5083 – Special Access

Long Distance Network Services

10. FCC 5100 – Long Distance Message

Miscellaneous – 5200

11. Transport and Termination of Local Telecom Traffic

12. Unbundled Network Elements

13. Private Mobile Telephone Services

14. Collections Overages

15. Charges Customer Checks Returned -

Nonpayment

16. Late Payment Charges

17. All Other Taxable Sources - Attach Schedule

18. FCC 5230 – Directory (Class A Account)

19. FCC 5280 – Nonregulated Operating Income

20. FCC 7100 – Other Operating Income

21. FCC 7300 – Nonoperating Income

22. All Other Nontaxable Sources – Attach Schedule

23. Total Taxable Receipts

(Sum of Line 1 through Line 22)

24. Tax (Line 23 times tax rate - See Instructions)

25. Tax Credits (Applies to Interstate

and Mobile only)

26. Tax (Line 24 minus Line 25)

27. Source of Report Information (A=FCC, B=PUC, C=Federal Tax)

Preparer’s Information:

28. Accounting method for GRT (A=Accrual, B=Cash, C=Other)

Firm Name

Individual Preparer Name

Firm FEIN

Phone

Address

City

Social Security Number

or PTIN

State

ZIP

1110014205

I affirm under penalties prescribed by law this report, including any accompanying schedules and statements, has been prepared by me and to the best of my

knowledge and belief is a true, correct and complete report.

Signature of Preparer

Date

Signature of Preparer – Please sign after printing

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