Carrier Remittance Worksheet - Nevada Universal Service Fund - 2001
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1State of Nevada Universal Service Fund
FY 2001 Carrier Remittance Worksheet
B. Revenue Data Period:
Please read complete instructions before completing.
C. o Quarterly
o Annual
A.
Company Code: NV –
D. o Original
o Revision
S
1 – C
I
ECTION
ARRIER
DENTIFICATION
1.
Company Name:
1a. Complete Mailing Address:
1b. Telephone:
2. Primary Communications Business (Please “X” primary business and “ü” other categories being reported):
o ILEC o IXC o RES o CLEC o CAP o CELL o PCS o OSP o PSP o PAG o Other (Explain)
3.
Parent Company:
3a. Complete Mailing Address:
3b. Telephone:
S
2 – Q
I
R
R
D
ECTION
UARTERLY
NTRASTATE
ETAIL
EVENUE
ATA
4. LOCAL EXCHANGE SERVICE...................................................................................................................................
4.
5. LOCAL PRIVATE LINE..............................................................................................................................................
5.
6. WIRELESS QUARTERLY CHARGES..........................................................................................................................
6.
7. WIRELESS USAGE CHARGES ..................................................................................................................................
7.
8. INTRASTATE SWITCHED TOLL.................................................................................................................................
8.
9. TOLL PRIVATE LINE................................................................................................................................................
9.
10. ALTERNATIVE ACCESS & DIRECTORY.....................................................................................................................
10.
11. PAY TELEPHONE....................................................................................................................................................
11.
12. MISCELLANEOUS CHARGES ...................................................................................................................................
12.
13. TOTAL INTRASTATE RETAIL REVENUES (SUM OF LINES 4 THROUGH 12) .................................................................
13.
S
3 – R
C
ECTION
EMITTANCE
ALCULATION
N / A
14. 2001 NUSF CONTRIBUTION RATE...........................................................................................................................
14.
N / A
15. GROSS NUSF ASSESSMENT (LINE 13 x LINE 14)......................................................................................................
15.
N / A
16. NPUC AUTHORIZED NUSF SUPPORT PAYMENT ......................................................................................................
16.
(Order No. _______________ Authorizing Support Payable)
N / A
17. NET NUSF REMITTANCE (LINE 16 – LINE 17) (Negative amount in Line 18 means NUSF payout)...............................
18.
S
4 – C
C
S
ECTION
HANGE IN
OMPANY
TATUS
18. New Carrier Name:
Date:
19. If business has been discontinued in Nevada:
Business Sold or
Business Merged or
Business Discontinued
(date)
(date)
(date)
20. Company sold to or merged with:
20a. If new business, date operations started in Nevada:
S
5 – C
ECTION
ERTIFICATION
21.
Date
Officer Name
Officer Signature
Officer Title
22.
Date
Contact Name
Contact Phone
Contact Title
23. Complete Contact Mailing Address:
Submit this worksheet to:
NECA NVUSF Fund Manager
80 S. Jefferson Road
Whippany , NJ 07981
(973) 884-8011 (Phone)
(973) 884-8510 (Fax)
Internet
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