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TELECOMMUNICATIONS UNIVERSAL ACCESS FUND (UAF)
REVISED UNIVERSAL ACCESS FUND QUARTERLY DEPOSIT REPORT
FOR THE QUARTER ENDED: ________________________
From (Company): Current Address:
__________________________________________
(Name that appears on your Certificate)
__________________________________________
(Name in which you are doing business)
___________________________________________ __________________________________________
(Any other name used)
GPSC Certificate Number(s): _____________________________________________________
(e.g., L-001, R-001, X-001, etc.)
Prepared By: _______________________________
Phone Number: _____________________________
Email: ____________________________________
1. Quarterly Revenue: $
2. Contribution Factor: 4.9% (0.049)
3. Quarterly Contribution Requirement = (1) x (2) = $
******
The amount of your quarterly deposit to GPSC UAF equals the amount on line 3 above. However, if the amount on line 1 is less than $12,500, no contribution is required. Simply mail or email the completed form to the Commission at the address shown below.
IF A REMITTANCE IS REQUIRED
(Sign and mail, email or fax a copy of this report to):
Dorothy Buckner HYPERLINK "mailto:dorothyb@psc.state.ga.us" dorothyb@psc.state.ga.us Fax: (770) 342-3024
Telecommunications Unit
Georgia Public Service Commission
244 Washington Street, SW
Atlanta, GA 30334-5701
(Include a copy of the remittance along with the copy of the report to GPSC).
(Revised 5/17/17)
Remit funds shown on line 3 of the preceding page (if the amount is $175.00 or more), via one of the following methods. Please indicate the method used:
FORMCHECKBOX Wire funds to: Wells Fargo
Atlanta, GA
ABA 121000248
Credit: GPSC UAF
Via USPS: Via Overnight:
FORMCHECKBOX Make checks payable to: GPSC UAF GPSC UAF
P.O. Box 934025 3585 Atlanta Avenue
Atlanta, GA 31193-4025 Hapeville, GA 30354
(Attach a copy of remittance form)
FORMCHECKBOX For companies that are Wells Fargo customers:
Contact Wells Fargo Treasury Management Client Services at (800) 289-3557, Option 2 to initiate a transfer of funds.
2. IF NO FUNDS ARE REQUIRED:
Complete lines 1, 2, and 3 on the previous page. Sign and mail, email, or fax this statement to:
Dorothy Buckner HYPERLINK "mailto:dorothyb@psc.state.ga.us" dorothyb@psc.state.ga.us Fax: (770) 342-3024
Telecommunications Unit
Georgia Public Service Commission
244 Washington Street, SW
Atlanta, GA 30334-5701
I certify, under penalty of law, that the above information is true and correct to the best of my knowledge and belief and as of the date indicated, I have remitted the required assessment to the fund administrator.
___________________________________________ _________________________________________
Authorized Signature Title
___________________________________________ _________________________________________
Printed Name Date
(Revised 05/17/2017)
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