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Get OR Form 751 2013-2021

OREGON PUBLIC UTILITY COMMISSION RESIDENTIAL SERVICE PROTECTION FUND RSPF RSPF SURCHARGE REMITTANCE FORM Telecommunications providers must collect remit the RSPF surcharge on all customer lines with access to OR Telecommunications Relay Service OTRS. Total surcharge amount due Line 3 X Line 4 6. Adjustments TOTAL AMOUNT DUE Signature Required - Print Sign Date I certify this report is true and correct and complies with Oregon Laws 1987 Chapter 290 Section 7. Mail report and payment to Public Utility Commission Residential Service Protection Fund PO Box 2153 Salem OR 97308-2153 Make checks payable to CHECK CORRESPONDING BOX FOR Amended Return Mailing Address Change OR report/remit online at http //apps. rspf.org Final Report Please refer to FORM 751 Guidelines for help in filling out this form. If you have questions contact Frank Lackey RSPF Compliance Specialist 503 378-4927 or frank. Report Period Month/Year PROVIDER Contact Name PUC Assigned Company ID responsible for verification of submitted info PROVIDER Address Telephone City State ILEC ZIP Email CLEC Radio Common Carrier wireless PREPARER Name Company Name PREPARER Address The RSPF surcharge remittance form and payment are due on or before the 21st calendar day following the reporting month. Late reports and payments are subject to late reporting fees penalties and interest pursuant to OAR 860-001-0050. 1. Total number of access lines and wireless instruments billed and unbilled during report period 2. Subtractions/Exemptions a* Unpaid access line and wireless instrument billings b. Number of lines paid by others due to interconnection agreements c* Exempt entities i. Counties or political subdivisions ii. Federal state and municipal government bodies or public corporations including regional housing authorities Federally chartered corporations specifically exempt from state excise taxes by federal law iv* Federally recognized Native American Tribes and tribal members who live within federally recognized Native American territory and are enrolled members of the tribe with sovereignty over that Native American territory v* Foreign government offices and representatives that are exempt from state taxation by treaty provisions d. Unbilled access lines e. Other Total Subtractions/Exemptions Lines 2a - 2e 4. Current surcharge per access line/wireless instrument 5. Total surcharge amount due Line 3 X Line 4 6. Adjustments TOTAL AMOUNT DUE Signature Required - Print Sign Date I certify this report is true and correct and complies with Oregon Laws 1987 Chapter 290 Section 7. Mail report and payment to Public Utility Commission Residential Service Protection Fund PO Box 2153 Salem OR 97308-2153 Make checks payable to CHECK CORRESPONDING BOX FOR Amended Return Mailing Address Change OR report/remit online at http //apps. Report Period Month/Year PROVIDER Contact Name PUC Assigned Company ID responsible for verification of submitted info PROVIDER Address Telephone City State ILEC ZIP Email CLEC Radio Common Carrier wireless PREPARER Name Company Name PREPARER Address The RSPF surcharge remittance form and payment are due on or before the 21st calendar day following the reporting month. Late reports and payments are subject to late reporting fees penalties and interest pursuant to OAR 860-001-0050. .

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