Form Psc/cmp 001 - Alternative Access Vendor Regulatory Assessment Fee Return
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1
2TO AVOID PENALTY AND INTEREST CHARGES, THE REGULATORY ASSESSMENT FEE RETURN MUST BE FILED ON OR BEFORE «Field1»
Alternative Access Vendor Regulatory Assessment Fee Return
Florida Public Service Commission
FOR PSC USE ONLY
STATUS:
Check # __________________________
(See Filing Instructions on Back of Form)
«Field2»
Actual Return
$ _________________
06-03-001
Estimated Return
003001
Amended Return
$ _________________ E
$ _________________ P
06-03-001
PERIOD COVERED:
004011
«Field3»
$ _________________ I
Postmark Date __________________
Initials of Preparer ______________
Please Complete Below If Official Mailing Address Has Changed
(Name of Company)
(Address)
(City/State)
(Zip)
LINE
FLORIDA GROSS
NO.
WIDE AREA TOLL SERVICES
OPERATING REVENUE
INTRASTATE REVENUE
1.
Special Access Services
$
$
2.
Private Line Services
3.
Leased Facilities & Circuits Services
4.
Miscellaneous Services
$
5.
TOTAL REVENUES
(1)
6.
LESS: Amounts Paid to Other Telecommunications Companies
7.
NET INTRASTATE OPERATING REVENUE for Regulatory Assessment
$
Fee Calculation (Line 5 less Line 6)
8.
Regulatory Assessment Fee Due (Multiply Line 7 by 0.0020)
9.
Penalty for Late Payment (see “3. Failure to File by Due Date” on back)
10.
Interest for Late Payment (see “3. Failure to File by Due Date” on back)
11.
Extension Payment Fee (see “4. Extension” on back)
$
(2)
12.
TOTAL AMOUNT DUE ($600.00 MINIMUM)
(1) These amounts must be intrastate only and must be verifiable (see "2. Fees" on back).
(2) Regardless of the gross operating revenue of a company, a minimum annual regulatory assessment fee of $600 shall be imposed as provided in
Section 364.336, Florida Statutes
COMPANY INFORMATION
Do you lease telecommunications’ facilities?
( ) YES
( ) NO
If YES, who do you lease these facilities from? Name:
Address:
I, the undersigned owner/officer of the above-named company, have read the foregoing and declare that to the best of my knowledge and belief the above
information is a true and correct statement. I am aware that pursuant to Section 837.06, Florida Statutes, whoever knowingly makes a false statement in writing with
the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree.
(Signature of Company Official)
(Title)
(Date)
Telephone Number
(
)
Fax Number (
)
(Preparer of Form - Please Print Name)
F.E.I. No.
PSC/CMP 001 (Rev. 04/07)
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