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IDAHO TELECOMMUNICATIONS SERVICE
ASSISTANCE PROGRAM FORM
DUE DATE: TWENTIETH OF MONTH
COMPANY NAME
REPORTING PERIOD:
TO
SURCHARGE REVENUES:
RESIDENTIAL
BUSINESS
& WIRELESS
SURCHARGE
END USERS
X
=
REVENUES
RESIDENTIAL ACCESS LINES
BUSINESS ACCESS LINES
WIRELESS ACCESS LINES
ASSISTANCE REVENUES:
ITSAP
TOTAL ASSISTANCE
RECIPIENTS
CREDIT
TOTAL CREDIT PAID TO RECIPIENTS
TOTAL DUE:
NET SURCHARGE REVENUES (SURCHARGE LESS CREDITS & ADMINISTRATIVE COSTS)
PREPARED BY:
PHONE:
Questions? Call alyson anderson, admin.
PLEASE MAKE CHECKS PAYABLE TO
TOTAL ACCESS LINES
PRORATED CHARGES
TOTAL SURCHARGE REVENUES
IDAHO TELECOMMUNICATIONS SERVICE ASSISTANCE PROGRAM
e-mail
alyson_anderson@msn.com
1964 north 300 east
centerville, ut 84014
PHONE (801) 294-5343 FAX (801) 294-5143
COSTS OF PROGRAM ADMINISTRATION
E-MAIL:
REVISED 5/17
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$0.00
$0.00
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$2.50