Colorado Telecommunications Relay Service Surcharge Form
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1COLORADO TELECOMMUNICATIONS RELAY SERVICE SURCHARGE
STATE OF COLORADO
PUBLIC UTILITIES COMMISSION
COMPANY NAME: ___________________________________________________
FOR THE MONTH OF: ________________________________
NUMBER OF LINES: ___________________
SURCHARGE @ $.10 PER LINE: ___________________
ADJUSTMENT TO CUSTOMER BILLS: ___________________
LESS VENDOR’ S FEE @ 0.75% ___________________
TOTAL REMITTANCE: ___________________
APPROVED BY:
___________________________________
DATE:
___________
COMPANY REPRESENTATIVE
TITLE: __________________________________________________________
COMPANY ADDRESS:
__________________________________________________________
__________________________________________________________
__________________________________________________________
QUESTIONS MAY BE DIRECTED TO:
____________________________________________
TITLE: ____________________________________________
AT
(
) ____________________
TELEPHONE #
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