Carrier Remittance Worksheet-For All Carriers Other Than Incumbent Lecs - 2009/2010

Kansas Universal Service Fund

Mar 09 - Feb 10 Carrier Remittance Worksheet

For all carriers other than Incumbent LECs

A. Company Code KS

E. Revenue Data Month(s):

B. Submission Date

Mar-09

Jun-09

Sep-09

Dec-09

C. KUSF Assessment Collected from Customers:

Apr-09

Jul-09

Oct-09

Jan-10

(Collected for Revenue Data Months Reported in Block E)

May-09

Aug-09

Nov-09

Feb-10

$____________________

1st QTR

2nd QTR

3rd QTR

4th QTR

D. Circle Reporting Basis:

Safe Harbor

Study

Actual

Semi-Annual Mar -Aug. 09

Semi-Annual Sep - Feb 10

Annual Mar 09 - Feb 10

F:

ORIGINAL

REVISION

Please read complete instructions before completing.

SECTION 1 - CARRIER IDENTIFICATION

1.

Company Name

1a.

Complete Mailing Address

1b.

Company Contact Name

1c.

Telephone:

E-Mail Address:

2. Primary Communications Business (Please circle primary business and "X " other categories being reported):

CLEC

IXC

CEL

PAG

VoIP

CAP

OSP

PAY

Other: Please Explain:

Agent - Attachment B must be filed for current fiscal year

3.

Agent Name:

3a.

Complete Mailing Address:

3b.

Agent Contact Name

E-Mail Address (required):

3c.

Telephone

SECTION 2 - INTRASTATE RETAIL REVENUE DATA

4. LOCAL EXCHANGE SERVICE…………………………………………...…………………………………………………………………………………

4 .

5. LOCAL/ INTRASTATE TOLL PRIVATE LINE……………………………...…………..…..…..……………………………

5 .

6. WIRELESS/PAGING CHARGES

(Include AirTime and

Roaming) ……………………..…….………

6 .

7. INTERCONNECTED VoIP………………………………………………………………….….……….………..…….………..………...………….……………...…….………..

7 .

8. INTRASTATE SWITCHED TOLL/LONG DISTANCE …...………………………………………………………………………

8 .

9. ALTERNATIVE ACCESS, PAYPHONE, & DIRECTORY………………………………………………………………………………

9 .

10. MISCELLANEOUS & NON-RECURRING …………………………………………………………………………………………………….

10 .

$

-

11. TOTAL INTRASTATE RETAIL REVENUE (SUM OF LINES 4 THROUGH 10)

…………

11 .

(see instructions)

12. UNCOLLECTIBLES (BAD DEBT) written off during this reported revenue data month ……………

12 .

$

-

13. NET INTRASTATE REVENUE (SUBTRACT LINE 12 FROM 11)……………………………………………………………

13 .

SECTION 3 - REMITTANCE CALCULATION

0.0503

14. 09/10 ASSESSMENT RATE

(All Carriers except

ILEC-local)

14 .

15. TOTAL NUMBER OF ACCESS LINES (

ILECS ONLY …………………………………

15 .

See Instructions)

$

-

16. GROSS KUSF ASSESSMENT (Line 13 x Line 14) …………………………………………………………………………………………………………….

16 .

17. KUSF SUPPORT PAYABLE ( Competitive ETCs ONLY) ………………………………………………………………………………………………

17 .

18. LIFELINE DISCOUNT [Facilities-Based providers]

# Lifeline

Discount

Total Lifeline

Incumbent LEC

Discount

Lines

Per Line

$

-

$

-

-

-

$

-

Total

18 .

-

19. TOTAL KUSF ASSESSMENT (LINE 16 - LINE 17 - LINE 18

19 .

)………………………………………………………………………………………………………………..

20. ASSESSMENT TRANSFERRED TO ILEC AFFILIATE (DUE TO KS00_____________) ILECS ONLY ………………………………………………………………………………………….

20 .

-

21. NET KUSF ASSESSMENT/(PAYMENT) DUE (LINE 19 + LINE 20

21 .

)………………………………………………………………………………………………………………..

Remittance Worksheets and Payments are due on the 15th day of the current month, unless on a weekend, then due the next business day.

Remittance worksheets received by GVNW after the due date are subject to a 1.0% (12% APR) or $100, whichever is greater, Late Worksheet Charge.

Payments received by CoreFirst after the due date are subject to a 1% (APR 12%) Late Payment Charge.

SECTION 4 - CHANGE IN COMPANY STATUS

22. Change in Business Operations:

Business Sold:____________

Business Merged:_______________

Business Ceased:__________________

(Date)

(Date)

(Date)

23. Surviving Legal Entity: ___________________________________________

24. Company Sold to/Merged With:_____________________________________

SECTION 5 - CERTIFICATION

Under penalties as provided by law, I certify that I have examined this report and to the best of my knowledge and belief it is true, correct and complete. I acknowledge GVNW's authority to request additional information as necessary.

25

Date

Officer Name

Officer Signature

Title

26

Date

Agent Name

Agent Signature

Title

Send Payment to: KUSF, PO Box 1512 Topeka, KS 66611-1512

Send CRW to: GVNW Consulting, Inc. 3220 Pleasant Run, Springfield, IL 62711

Questions: 217.862.1550

E-Mail:

Fax: 217.698.2715

KUSF 2009/2010