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)
th
Due Date: 20
of the month following reporting month
th
(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