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Independent Payphone Provider (Ipp) Revenue Statement For Calendar Year Form - Department Of Telecommunications And Cable

COMMONWEALTH OF MASSACHUSETTS

DEPARTMENT OF TELECOMMUNICATIONS AND CABLE

Independent Payphone Provider (IPP)

Revenue Statement for Calendar Year Ending December 31, ______

1. Exact name of reporting company

____________________________________________________________________________________

2. Doing Business as (DBA) in MA, if any

________________________________________________________________________________________________________

3. Federal Identification Number (FIN)

________________________________________________________________________________________________________

4. If filing a combined statement, list registered names and (FINs) of all joint filers:

Registered name(s) DBAs and FINs

_____________________________________________________________________________________

5. MA intrastate operating revenue $

_____________________________________________________

6. MA intrastate operating expenses $

_____________________________________________________

CONTACT INFORMATION Questions regarding the information provided in this return, and

regulatory assessment invoices should be directed to:

[ ] Please check if contact information has changed since last filing.

Contact person/Title____________________________________________________________________

Address ______________________________________________________________________________

Contact person telephone number _________________ Contact person E-

mail______________________

I hereby certify, under penalty of perjury, that the foregoing statement is true to the best of my

knowledge and belief.

Date____________________________Signature____________________________________________

Name/Title (typed or printed)

Please issue a check in the amount of $5.00 payable to the Commonwealth of MA-DTC. Do not staple

the check to forms. Mail original IPP Revenue Statement and one (1) photocopy, along with the

original check, and two (1) photocopy of the check to:

MA Department of Telecommunications & Cable

Attn: Competition Division

1000 Washington Street, Suite 820

Boston, MA 02118-6500

Independent Payphone Provider (Ipp) Revenue Statement For Calendar Year Form - Department Of Telecommunications And Cable