Form T-S- Wisconsin Telco Statewide Summary Return

Form T-S- Wisconsin Telco Statewide Summary Return - 2013 Page 3

WISCONSIN TELCO STATEWIDE SUMMARY RETURN

FORM

2013

T-S

ASSESSMENT DATE: JANUARY 1, 2013

Page 1

DUE DATE:

March 1, 2013

ENTER TELCO COMPANY DATA BELOW

FOR DEPARTMENT USE ONLY

Telco FEIN #

Telco #

Initial

Date

STAMP

Telco Name 1

Audit

_______

Name 2

PENALTY

Address 1

Address 2

City

State

Zip

(R. 01-13)

2/4/2013 13:03

This company operates under these names:

TELCO TYPE

TELCO I.D. #

FEIN #, IF DIFFERENT THAN SHOWN ABOVE:

Complete this T-S Form which summarizes all telephone company assets located in Wisconsin. This form is a summary of the statewide T-P Form and

individual T-R forms filed by your company for property throughout the state of Wisconsin. Filing this T-S Form does not negate the necessity of filing other T-

Forms.

Telco Types

ILEC - Incumbent Local Exchange Carrier

FBR - Optical Fiber

CLEC - Competitive Local Exchange Carrier

TWR - Tower

IXC - Interexchange Carrier

OTHR - Other

I, the undersigned, declare under penalties of law that I have personally examined this return and to the best of my knowledge and belief it is true, correct and complete.

NOTE: Original signature is required

Type Name

PREPARER

EXT. #

Signature

Telephone Number

SIGN

HERE

Firm Name or Title

Date

FAX Number

Type Name