HomeMy WebLinkAboutItsapform.pdfIdaho Telecommunications Service Assistance Program Form
Due Date: 20th of Each Month
Company Name: ______________________________________________________________
Reporting Period: _________________________________ TO _________________________
Surcharge Revenues: Residential Business and
Wireless End Users
X
Surcharge
= Surcharge Revenues
Residential
Access Lines
__________________
Business Acces
Lines
__________________
Wireless Access
Lines
__________________
Total Access
Lines
__________________ $0.00 __________________
Prorated Charges ___________________
Total Surcharge Revenues ___________________
Assistance Revenues: Recipients X ITSAP
Credit =
Total Assistance
Revenues
Total Credit Paid to
Recipients
__________________
$2.50
__________________
Total Due:
Costs of Program Administration
__________________
Net Surcharge Revenues
(Surcharge Less Credits and Administrative
Costs)
__________________
Prepared By: _____________________________________ Phone ______________________
Email: ___________________________________________
Questions? E-mail Kelli Toohill at IdahoTSAP@gmail.com or call at 406-697-4343.
PLEASE MAKE CHECKS PAYABLE TO: Idaho Telecommunications Service Assistance Program (ITSAP)
PO Box 270727/566 S McCaslin Blvd Unit 270727
Louisville, CO 80027 Rev. 08/23