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Bill For Collection Schedule On Computation Of The Public Utility Fee - Public Utilities Commission State Of Hawaii

PUBLIC UTILITIES COMMISSION

STATE OF HAWAII

BILL FOR COLLECTION

SCHEDULE ON COMPUTATION OF THE PUBLIC UTILITY FEE

AND

COMMERCIAL MOBILE RADIO SERVICE ("CMRS") STATEWIDE SUBSCRIBER COUNTS

Payment is for:

Check One:

_______ July 31st payment

_______ December 31st payment

(Note: July and December Fee payments based on prior year revenues, two payments required per year.

For example: July and December 20X4 payment based on calendar year 20X3 revenues, See Hawaii Revised

Statutes Section 269-30.

CMRS providers include two most recent subscriber data filed with the FCC.

NAME OF COMPANY:

ADDRESS:

SECTION I

GROSS REVENUES FOR CY 20_____

-------------------------------------------------

FEE = .0025 x LINE 1

-------------------------------------------------

GREATER OF LINE 2 OR $30 (MINIMUM DUE)

=================================

PLEASE PAY THE AMOUNT ON LINE 3 AND SEND YOUR REMITTANCE WITH A COPY OF THIS BILL TO:

PUBLIC UTILITIES COMMISSION

465 S. KING STREET, ROOM 103

HONOLULU, HAWAII 96813

JULY PUBLIC UTILITY FEE PAYMENT IS DUE ON OR BEFORE JULY 31st.

DECEMBER PUBLIC UTILITY FEE PAYEMENT IS DUE ON OR BEFORE DECEMBER 31st.

MAKE CHECK PAYABLE TO THE PUBLIC UTILITIES COMMISSION

SECTION II

TO BE COMPLETED BY CMRS PROVIDERS ONLY: (In accordance with Hawaii PUC Decision and Order No. 20890)

As of June 30, 20______

As of December 31, 20_____

Number of Statewide Subscribers

(provide two most recent subscriber

counts filed with the FCC)

CMRS Providers must also send a copy of this bill to:

Division of Consumer Advocacy

335 Merchant Street, Room 326

Honolulu, HI 96813

VERIFICATION

SECTION III

I, _________________________________________________________, CERTIFY THAT I AM DULY AUTHORIZED TO VERIFY

(Print or Ty

INFORMATION CONTAINED HEREIN AND THAT THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIE

__________________________________________________________

________________________________________

SIGNATURE

DATE

__________________________________________________________

________________________________________

TITLE

PHONE NUMBER

PUC USE ONLY

DATE PAID:

AMOUNT PAID

CHECK NO.:

BANK:

(Revised 12-16-04)

Bill For Collection Schedule On Computation Of The Public Utility Fee - Public Utilities Commission State Of Hawaii

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