FORM A FOR RESELLERS, COMPETITIVE PROVIDERS, VOIP, CLECs, and OTHER TELECOMMUNICATIONS
Utility License Fee Report Form - City of Portland, Oregon
This form for use by all companies subject to City Code Section 7.14
Filed forms are confidential per City Code Section 7.14.130.
LINE 1a Name of Company:_______________________________________________________
LINE 1b Utility License Number: ________________________________
LINE 1c Address (city, state, zip):_______________________________________________________
LINE 2 Reporting Period: Year:_______ Quarter: ___Jan-Mar ___Apr-Jun ___Jul-Sep ___Oct-Dec
LINE 3 Total Revenues Earned in Portland for Reporting Period: $________________
LINE 4 Revenues Earned in Portland Not Subject to Fee:
( list all by source and amount; attach additional pages if needed )
1. Uncollectibles. 7.14.040.E. $________________
2. Specified wholesale. 7.14.040.E.2.a $________________
3. Specified public purposes charges.
4. Federal, state, or local law limitations.
7.014.080.B (specify). $________________
5. Customer late fees & interest $________________
6. Other (specify) $________________
LINE 5 Revenues Derived in Portland Subject to Fee ( subtract LINE 4 from LINE 3 ) $________________
LINE 6 Applicable compensation rate (See Code Section 7.14.060.A) %: _____5___
LINE 7 Subtotal of fee ( multiply LINE 5 by LINE 6 ) $________________
LINE 8 Other Credits / Adjustments ( list all by source and amount; attach additional pages if needed ):
1. Franchise or other fees for use of the streets.
7.14.070.A. $ ________________
2. Other (specify) $________________
TOTAL FEE ( Subtract LINE 8 from LINE 7 for net credits; add
LINE 9 LINE 8 to LINE 7 for net debits ) $________________
Print name, title, telephone number and email address
I hereby certify that all statements made in this report and any of its attachments are true, complete and accurate to
the best of my knowledge.
Remit to: Office of Cable Communications and Franchise Management. Call 503-823-5385 or email
firstname.lastname@example.org for wiring instructions or to make other payment arrangements.
Form issue date: 12/29/09