telecommunications service provider annual report · (electronic signature - type name)* (title)...
TRANSCRIPT
Telecommunications Service Provider Annual Report
GENERAL INSTRUCTIONS
The Telecommunications Service Provider annual report (Form TC-1) is a PDF fillable form that must be completed and uploaded to the Iowa Utilities Board's electronic filing system (EFS) by telecommunications service providers. This form includes data used by the Board to compile reports and to calculate the company's assessable revenue for billing purposes.
This form MUST be downloaded and saved to your computer prior to entering data.
Forms are available on the Board's web site at https://iub.iowa.gov/records-information/file-utility-annual-report.
Information should be filed on a CALENDAR year basis.
Information regarding the number of telecommunications service numbers for a company may be filed as confidential. If a confidential filing is made, the company is required to also file a public version with the confidential information redacted. Contact the Board’s EFS Help Desk by email to [email protected] or by phone at 515.725.7337 for information on how to make a confidential filing.
The filing should be submitted in a company’s M docket using its four-digit company number (M-XXXX). For your convenience, the attestation page includes a “Save and Submit” button. After completing the form, click the button and a Save dialog box will open. After saving, a browser window will open on the login page of EFS. When filing in EFS please use the following naming conventions:
Form Filing Title Document Title
TC-1 2019 Telecommunications Service Provider Annual Report
2019 Telecommunications Service Provider Annual Report
Annual reports must be uploaded to the EFS on or before April 1
Iowa Utilities Board Contact:
Customer ServiceIowa Utilities Board 1375 E Court Ave Des Moines, IA 50319-0069 [email protected]
Form TC-1
IOWA UTILITIES BOARD TELECOMMUNICATIONS SERVICE PROVIDER
ANNUAL REPORT FORM OF
Company Name
For the Year Ended
Pursuant to 199 IAC 23.1(2), an annual report is required to be filed with the IUB each year. The information contained in the annual report is needed to meet the IUB's statutory obligations. Please provide the following information for your telecommunications service provider to aid in the compilation of this information.
COMPANY CONTACT INFORMATION(All Telecommunications Service Providers)
PRIMARY/REGULATORY CONTACT: The person to whom official Iowa Utilities Board mailings and notifications should be sent.
Title E-Mail Address (required)Company Name
State Zip Code Fax
DBA (Doing Business As)
Address
City Phone
COMPLAINT CONTACT:
E-mail Address (required)Phone (required)Secondary E-Mail Address (Optional)Customer complaints filed with the IUB are sent electronically. Provide a name, telephone number, and permanent E-mail address where the complaints should be sent. To designate a secondary/group email address to receive complaints, complete the optional secondary email address field
ACCOUNTS PAYABLE/ASSESSMENTS: E-Mail Address (required)Phone (required)Secondary E-Mail Address (Optional)Iowa Utilities Board assessments are sent electronically. Provide a name, telephone number, and permanent E-mail address where assessments should be sent. To designate a secondary email address to receive copies of invoices, complete the optional secondary email address field.
EMERGENCY CONTACT:
Title Phone (required)
This should be an operations position staffed 24 hours/day, such as a control center or an operations dispatcher. For smaller utilities this should be a 24x7 cell phone or pager, or the home phone number where the responsible person may be reached, or alternatively a municipal police-fire dispatcher. Please do not use a 24 hour customer service number unless you also provide an alternate number that is accessible during an outage or emergency.
Original Filing
Revised Filing
Page 1 of 3 Revised 2019
Company Number:Form TC-1
Certification of notification: Notification as required by 199 IAC 22.3 was completed (please mark YES or NO) YES NO
UNCLAIMED PROPERTY(All Telecommunications Service Providers)
Pursuant to Iowa Code sections 556.4 and 556.11, unclaimed deposits and refunds held for more than one year after termination of service are considered abandoned and escheat to the state treasurer.
Provide the dollar amount of unclaimed property reported to the state treasurer for the fiscal year ended June 30, 2019. $ _______________
If the dollar amount reported is zero, does the company have an unclaimed property procedure in place? (please mark YES or NO) YES NO
Provide the company FEIN and contact information for the person responsible for reporting unclaimed property. This information will be reported to the Treasurer of State.
Page 2 of 3 Revised 2019
NOTIFICATION OF THE COMPLAINT PROCESS (Local Exchange Telecommunications Service Providers Only)
199 IAC 22.3 requires that local exchange telecommunications service providers notify their customers annually about how they can contact the utility with complaints. The notice must also inform customers that if the utility does not resolve their complaint, they can file a written complaint with the Utilities Board.
To review the full notification requirement, refer to the rule number.
Name:
Email Address:
Telephone:
FEIN:
ASSESSABLE REVENUES & TELECOMMUNICATIONS SERVICE NUMBERS INFORMATION
(All Telecommunications Service Providers)
Iowa Gross Operating Revenues $
Telecommunications Service Numbers as of
"Iowa Gross Operating Revenues" means all revenues from Iowa intrastate telecommunications service provider operations that are subject to the Board's jurisdiction during the calendar year. The company's portion of the industry direct and remainder assessments will be calculated on the basis of this revenue. See Iowa Code § 476.10.
“Telecommunications Service Numbers” means all revenue producing numbers. If none, enter 0.
Form TC-1 Company Number:
IOWA UTILITIES BOARD
ATTESTATION
I, certify that I am the Company Representative (Type or print the name of the individual)
responsible for the Annual Report of (Name of Company)
that I have examined the foregoing report, that to the best of my knowledge, information, and belief,
all statements of fact contained in said report are true and said report is a correct statement of the
business and affairs of the above-named respondent with respect to each and every matter set forth
therein during the period from January 1, , through December 31, , inclusive.
Date /s/ (Electronic Signature - Type Name)*
(Title)
(Street and Address)
(City, State, and Zip Code)
(Telephone Number)
(E-Mail Address)
*In lieu of an original signature, please sign by typing the name of the person. Annual reports withoriginal signatures are not accepted in the Electronic Filing System.
Page 3 of 3 Revised 2019
Company Number:Form TC-1