Form Ct-1 - Virginia Report Of Termination, Renewal, Acquisition Or Sale Of Cable Franchise Agreements In Effect On January 1, 2007

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Form CT-1

Report of Termination, Renewal, Acquisition or Sale of Cable Franchise Agreements

in Effect on January 1, 2007

• Beginning January 1, 2007, cable television providers are required to report each month the termination, renewal, acquisition or sale of any cable franchise agreement in effect on January 1, 2007.

• Form CT-1 is due no later than the 20th day of the month following the month the change takes effect.

• Make additional copies as needed or use your own schedule in the same layout as below.

• For assistance, call (804) 367-8037.

Business Name

Virginia Account Number

FEIN

Agreements in Force as of 1/1/07

Sold

Acquired

Begin

Termination

Date

Locality

FIPS Code*

Date

To Whom

Date

From Whom

This form must be signed by an officer of the corporation, limited liability company or unincorporated association, who is authorized to sign on behalf of the

organization. The proprietor must sign for a sole proprietorship.

Under penalty of law, I believe the information on this form to be true and correct.

Signature

Title

Name Printed

Date

Daytime Phone Number

* See back for FIPS codes

Va. Dept. of Taxation Form CT-1 W Rev 04/13