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Monthly Access Line Assessment Form - Arkansas Deaf And Hearing Impaired Telecommunications Services - Arkansas

Arkansas Deaf and Hearing Impaired

Telecommunications Services

(ADHITS)

1220 West Sixth

Little Rock, AR 72201

501-375-0086

Monthly Access Line Assessment Form

(In accordance with Act 1080 of 1997 Arkansas General Assembly)

Due Date: 20

of the month following reporting month

(i.e. January is due February 20

)

Reporting Month: ________________________

Year: _________

Company: _____________________________________________________________

Address: _______________________________________________________________

______________________________________________________________

Contact Person: ___________________________ Phone#: ____________________

FAX#:___________________ E-mail:_______________________________

Total Access Lines: ________________ X $0.04 = $ _________________

Adjustment:____________________

Explanation:_____________________________________________________________

_______________________________________________________________________

Total Remitted: $ _________________

As an authorized agent or officer of ________________________________________

I hereby certify that the above is true, complete and correct to the best of my

knowledge and belief.

_________________________________________

________________

Signature

Date

Make check payable to and return this check to:

ADHITS

c/o ATA, 1220 West Sixth, Little Rock, AR 72201

Do Not Alter Form

Proprietary and Confidential

Monthly Access Line Assessment Form - Arkansas Deaf And Hearing Impaired Telecommunications Services - Arkansas