Telecomunications Company Revenue And Assessment Report
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2Telecomunications Company Revenue and Assessment Report
Wyoming Universal Service Fund
Section I. General Company Information
Reporting Period
Internal Use Only
Docket Management System #
Invoice#
Company Name
Please check, if applicable:
Attention
Initial Report ( )
Address
Amended Report ( )
City, State, and Zip
Final Report ( )
Section II. Wyoming Intrastate Retail Revenue for the Reporting Period
1 Local Exchange Service
2 Local Private Line
3 Cellular/PCS/Mobile
4 Intrastate Switched Toll (Long Distance)
5 Alternate Access and Directory
6 Intrastate VOIP Services
7 Other Intrastate Retail Revenue (Paging, Pay Telephone, etc)_______________________
8 Other Services and Charges (Service Line Charges, etc)__________________
9 Total Wyoming Intrastate Retail Revenue ( Add lines 1 through 8)
10 Less: Wyoming Intrastate Retail Revenue from Wholesale Transactions
11 Total Wyoming Intrastate Retail Revenue (Line 9 - line 10)
Section III. WUSF Assessment for the Reporting Period
12 Amount from Line 11
13 WUSF Assessment Rate for the reporting period
14 Total WUSF Assessment (Line 12 x line 13)
Check here if #11 amount represents actual customer amount collected by company.
Section IV. Reconciliation with Prior Reporting Periods and Amount Due
15 Amount from line 14
16 Amount due from Prior Reporting Periods:________________________________
17 Credits to Apply from Prior Reporting Periods: ____________________________
18 Total Amount Due (Line 15 + line 16 - line 17)
Section V. Oath
Under penalty of perjury, I declare that I have examined this report, and that it is true, correct and complete to the best of
my knowledge, information, and belief.
Signature:_____________________________________________
Date:_______________________
Print Name and Title:________________________________________ Telephone Number:_____________________
Email:________________________________________________
To pay by EFT: Use routing # 121000248 and account # 4941332611 Payable to: WUSF/PSC/State of
Check here if paying by EFT.
Wyoming. Please submit this form via email to wusf@wyo.gov.
Make checks payable to: WUSF, 2515 Warren Avenue, Suite 300, Cheyenne, WY 82002
Check here if paid by check.
Please enclose this form with your mailed check.
Check #
Last Update 05/09/2016
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