ABCDEFGHIJKLMNOPQRSTUVWXYZ
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State of Alaska
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Universal Service FundA.Company Code:
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Monthly Carrier RemittanceB.Submission Date:
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WorksheetC.Revenue Data MM/YY:
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Please read instructions before completing.D.OriginalRevision
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SECTION 1 - CARRIER IDENTIFICATION
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1.Company Name:
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1.a.Complete Mailing Address:
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1.b.Telephone:
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1.c.Email Address:
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SECTION 2 - MONTHLY INTRASTATE END USER REVENUE DATA
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2.Local Service Revenues2.
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3.Wireless/PCS/Mobile/Paging Revenues3.
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4.Interexchange Switched Toll and Private Line Revenues4.
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5.Pay Telephone Revenues5.
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6.VoIP Revenues6.
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7.Other Revenues7.
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7.a.Less Uncollectible Revenue7.a.
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8.Total Intrastate End User Revenues (sum of lines 2 through 7.a.)8.
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SECTION 3 - REMITTANCE CALCULATION
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9.AUSF Rate (effective 01/01/2019)9.10.00%
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10.AUSF Amount Due (line 8 X line 9)10.
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Monthly worksheets and remittances must be received by AUSAC by the 20th calendar day of each month. If payment is not received in immediately available funds by the due date, interest at the rate of .000287, calculated on the total amount due, will be charged until the date paid. In addition to interest, if payment is not received in immediately available funds within two (2) days of the due date, a one-time liquidated damages sum equal to one percent (1%) of the total amount due will be charged.
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SECTION 4 - CHANGE IN COMPANY STATUS
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11.Date:
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12.
If business has been discontinued in Alaska:
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Business Sold
Business Merged
Business Discontinued
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(date)(date)(date)
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 12.a.
Company sold to or merged with:
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If business has recently started in Alaska,
business began.
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(date)
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SECTION 5 - CERTIFICATION
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Under penalties as provided by law, I certify that I have examined this report and to the best of my knowledge and belief it is true, correct, and complete. I further acknowledge AUSAC's authority to request additional supporting information as may be necessary.
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13.
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DateNameAuthorized SignatureTitle
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14.
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Contact NameContact TitlePhone Number
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15.
Signer's Mailing Address:
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16.
Signer's Email Address:
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Send worksheet and payment to:
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Alaska Universal Service Administrative Company
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Email: info@ausac.org
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Phone: (907) 561-6300
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Appendix 1
TA39-998
Effective: October 14, 2022
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